Provider Demographics
NPI:1306881172
Name:WELLIKOFF, DAVID MATTHEW (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MATTHEW
Last Name:WELLIKOFF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1133 SW BAKER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6830
Mailing Address - Country:US
Mailing Address - Phone:503-472-3341
Mailing Address - Fax:503-472-7916
Practice Address - Street 1:1133 SW BAKER ST
Practice Address - Street 2:SUITE A
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6830
Practice Address - Country:US
Practice Address - Phone:503-472-3341
Practice Address - Fax:503-472-7916
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00109213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT68251Medicare UPIN
OR0856870001Medicare NSC