Basic Information
| Provider Information | |||||||||
| NPI: | 1366470726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | G | ||||||||
| MiddleName: | GRAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 799 E HAMPDEN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037892663 | ||||||||
| FaxNumber: | 3037884871 | ||||||||
| Practice Location | |||||||||
| Address1: | 799 E HAMPDEN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037892663 | ||||||||
| FaxNumber: | 3037884871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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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 | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01166933 | 05 | CO | MEDICAID |