Healthcare Provider Details

I. General information

NPI: 1659891455
Provider Name (Legal Business Name): WELLER NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 211
GRESHAM OR
97030-3382
US

IV. Provider business mailing address

24900 SE STARK ST STE 211
GRESHAM OR
97030-3382
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-0435
  • Fax: 503-618-1859
Mailing address:
  • Phone: 503-669-0435
  • Fax: 503-618-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD17310
License Number StateOR

VIII. Authorized Official

Name: DR. KIRK L WELLER
Title or Position: OWNER
Credential: MD
Phone: 503-669-0453