Provider Demographics
NPI:1215946223
Name:WELLS, MARVIN LAWRENCE (DO)
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:LAWRENCE
Last Name:WELLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ROCK RUN RD.
Mailing Address - Street 2:
Mailing Address - City:FRIENDLY
Mailing Address - State:WV
Mailing Address - Zip Code:26146
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:300 ROCK RUN RD.
Practice Address - Street 2:
Practice Address - City:FRIENDLY
Practice Address - State:WV
Practice Address - Zip Code:26146
Practice Address - Country:US
Practice Address - Phone:313-563-3332
Practice Address - Fax:313-563-3342
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE39295Medicare UPIN