Provider Demographics
NPI:1235179144
Name:WELBORN, JOHN HEARST JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HEARST
Last Name:WELBORN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:HEARST
Other - Last Name:WELBORN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1700 SAN PABLO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2081
Mailing Address - Country:US
Mailing Address - Phone:510-724-4600
Mailing Address - Fax:510-964-0607
Practice Address - Street 1:1700 SAN PABLO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2081
Practice Address - Country:US
Practice Address - Phone:510-724-4600
Practice Address - Fax:510-964-0607
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61831207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A618310Medicaid
CA00A618311Medicare PIN
CAH42664Medicare UPIN