Healthcare Provider Details

I. General information

NPI: 1316920846
Provider Name (Legal Business Name): LAWRENCE M WELLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20917 UNION TURNPIKE
HOLLIS HILLS NY
11364
US

IV. Provider business mailing address

20917 UNION TPKE
HOLLIS HILLS NY
11364-3237
US

V. Phone/Fax

Practice location:
  • Phone: 718-464-2626
  • Fax: 718-464-2641
Mailing address:
  • Phone: 718-464-2626
  • Fax: 718-464-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number106532
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: