Provider Demographics
NPI:1104879964
Name:WELLS, GARY B (MD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:B
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-1268
Mailing Address - Country:US
Mailing Address - Phone:870-424-7070
Mailing Address - Fax:870-424-6616
Practice Address - Street 1:624 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2915
Practice Address - Country:US
Practice Address - Phone:870-424-2200
Practice Address - Fax:870-424-6616
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN77962085R0001X
ARN-77962085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115858001Medicaid
AR115858001Medicaid