Healthcare Provider Details

I. General information

NPI: 1417303504
Provider Name (Legal Business Name): WELLS WEYMOUTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4789
  • Fax:
Mailing address:
  • Phone: 912-435-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101262752
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD-23469
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: