Basic Information
| Provider Information | |||||||||
| NPI: | 1215926597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5350 FRANTZ RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164259 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 285 E STATE ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145669496 | ||||||||
| FaxNumber: | 6145668668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 35069832 | OH | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0105X | 35069832 | OH | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 0237603 | 05 | OH | MEDICAID |