1497763940 NPI number — DAVID EARL WELLENSTEIN M.D.

Table of content: TAJIA FEDERICK-WILLIAMS (NPI 1518746130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497763940 NPI number — DAVID EARL WELLENSTEIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLENSTEIN
Provider First Name:
DAVID
Provider Middle Name:
EARL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497763940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
185 GENESEE ST
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13501-2199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-793-8806
Provider Business Mailing Address Fax Number:
315-793-8046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 GENESEE ST
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13501-2199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-793-8806
Provider Business Practice Location Address Fax Number:
315-793-8046
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  132617 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300029077 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 225159 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00751524 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P010149411 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10043865 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4102251 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426013871 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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