1770858649 NPI number — DR. LAURENCE DAVID WELLIKSON M.D.

Table of content: DR. LAURENCE DAVID WELLIKSON M.D. (NPI 1770858649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770858649 NPI number — DR. LAURENCE DAVID WELLIKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLIKSON
Provider First Name:
LAURENCE
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
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:
1770858649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33631 CAPSTAN DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANA POINT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-400-4453
Provider Business Mailing Address Fax Number:
949-240-0573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33631 CAPSTAN DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANA POINT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-400-4453
Provider Business Practice Location Address Fax Number:
949-240-0573
Provider Enumeration Date:
03/12/2012

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: 207R00000X , with the licence number:  G27152 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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