Healthcare Provider Details

I. General information

NPI: 1750517330
Provider Name (Legal Business Name): JASON M. WELLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR PATHOLOGY DEPARTMENT
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

4619 KENNY RD
COLUMBUS OH
43220-2779
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3221
  • Fax:
Mailing address:
  • Phone: 614-457-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberMT195871
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number8566738-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101260185
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: