Healthcare Provider Details

I. General information

NPI: 1750324281
Provider Name (Legal Business Name): SAMUEL DAVID WELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 S TWIN ST
WEST JEFFERSON OH
43162-1442
US

IV. Provider business mailing address

PO BOX 951603
CLEVELAND OH
44193-0018
US

V. Phone/Fax

Practice location:
  • Phone: 614-879-8141
  • Fax: 614-879-9949
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-07-9160
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: