Basic Information
| Provider Information | |||||||||
| NPI: | 1659423754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLE | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1595 SOQUEL DR | ||||||||
| Address2: | STE 220 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314764200 | ||||||||
| FaxNumber: | 8314765052 | ||||||||
| Practice Location | |||||||||
| Address1: | 1595 SOQUEL DR | ||||||||
| Address2: | STE 220 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314764200 | ||||||||
| FaxNumber: | 8314765052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 20A7123 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BW5402906 | 01 | CA | DEA LICENSE | OTHER | 00AX71230 | 05 | CA | MEDICAID | 20A7123 | 01 | CA | STATE LICENSE | OTHER |