Healthcare Provider Details

I. General information

NPI: 1457302630
Provider Name (Legal Business Name): JEFFREY C WELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W 8TH ST
PORT ANGELES WA
98362
US

IV. Provider business mailing address

PO BOX 850
PORT ANGELES WA
98362-0146
US

V. Phone/Fax

Practice location:
  • Phone: 360-457-8578
  • Fax: 360-457-4841
Mailing address:
  • Phone: 360-417-7111
  • Fax: 360-417-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00037703
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: