Healthcare Provider Details

I. General information

NPI: 1962620740
Provider Name (Legal Business Name): MARCUS WELLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 WEST 7TH ST. CENTRAL ARKANSAS VETERANS HEALTCARE SYSTEM
LITTLE ROCK AR
72205
US

IV. Provider business mailing address

126 FOUNTAIN AVE
LITTLE ROCK AR
72205-5912
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-6585
  • Fax:
Mailing address:
  • Phone: 919-259-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberE-6668
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD037305
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: