Healthcare Provider Details

I. General information

NPI: 1790798593
Provider Name (Legal Business Name): LARRY L WELLENDORF II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 N MERRITT CREEK LOOP STE A
COEUR D ALENE ID
83814-4960
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-3670
  • Fax: 208-625-3675
Mailing address:
  • Phone: 208-625-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036091551
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMC-2626
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: