Provider Demographics
NPI:1316920846
Name:WELLS, LAWRENCE M (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:M
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 1:20917 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3237
Mailing Address - Country:US
Mailing Address - Phone:718-464-2626
Mailing Address - Fax:718-464-2641
Practice Address - Street 1:20917 UNION TURNPIKE
Practice Address - Street 2:
Practice Address - City:HOLLIS HILLS
Practice Address - State:NY
Practice Address - Zip Code:11364
Practice Address - Country:US
Practice Address - Phone:718-464-2626
Practice Address - Fax:718-464-2641
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106532207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY47785Medicare ID - Type Unspecified
C08527Medicare UPIN