Provider Demographics
NPI:1730199381
Name:WELLWOOD, JOHN DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:WELLWOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 CHAMBERS ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3728
Mailing Address - Country:US
Mailing Address - Phone:541-345-8734
Mailing Address - Fax:541-434-0102
Practice Address - Street 1:1350 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3728
Practice Address - Country:US
Practice Address - Phone:541-345-8734
Practice Address - Fax:541-434-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2385AT1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158916Medicaid
U32076Medicare UPIN
OR158916Medicaid