Provider Demographics
NPI:1053309633
Name:WELBOURNE, WILLIAM PORTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:PORTER
Last Name:WELBOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 NORTH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-787-5400
Mailing Address - Fax:315-787-5475
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5400
Practice Address - Fax:315-787-5475
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY119889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00447049Medicaid
NYP010119889OtherEXCELLUS
NY00447049Medicaid
NYP010119889OtherEXCELLUS