Provider Demographics
NPI:1487618542
Name:WELLS, LARRY JOE (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JOE
Last Name:WELLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1125 TROUPE ST
Mailing Address - Street 2:P.O. BOX 3845
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3845
Mailing Address - Country:US
Mailing Address - Phone:706-737-4575
Mailing Address - Fax:706-731-5289
Practice Address - Street 1:4350 TOWNE CENTRE DR
Practice Address - Street 2:SUITE 1000
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3301
Practice Address - Country:US
Practice Address - Phone:706-868-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0201642085R0202X, 2085D0003X, 2085B0100X, 2085N0904X, 2085U0001X, 2085N0700X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265540314OtherNPI - BROWN & RADIOLOGY
SCG20164Medicaid
GA00196952BMedicaid
GA00196952EMedicaid
GA278202OtherBLUE CROSS BLUE SHIELD
GA00196952DMedicaid
10059184OtherAMERIGROUP
10059184OtherAMERIGROUP
GA00196952EMedicaid