Healthcare Provider Details

I. General information

NPI: 1164602835
Provider Name (Legal Business Name): STEPHEN C WELLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E WHITESTONE BLVD STE A
CEDAR PARK TX
78613-7641
US

IV. Provider business mailing address

1420 VICEROY DR
DALLAS TX
75235-2208
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-5800
  • Fax: 512-459-1399
Mailing address:
  • Phone: 214-358-2300
  • Fax: 214-579-6941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberN5477
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: