Provider Demographics
NPI:1699705269
Name:WELLER, CLIFFORD F (DO)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:F
Last Name:WELLER
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 1:32-36 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1840
Mailing Address - Country:US
Mailing Address - Phone:570-723-0340
Mailing Address - Fax:570-723-8087
Practice Address - Street 1:32-36 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1840
Practice Address - Country:US
Practice Address - Phone:570-723-0340
Practice Address - Fax:570-723-8087
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011058L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018551790001Medicaid
PA0018551790001Medicaid
H39807Medicare UPIN