Provider Demographics
NPI:1700975406
Name:WELLS, THOMAS DAVID (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAVID
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100000 BAY PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744-0000
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:
Practice Address - Street 1:10,000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33708-0000
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57848207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063312700Medicaid
FLC23325Medicare UPIN
FL063312700Medicaid