Provider Demographics
NPI:1417051152
Name:WELLBORN, ROGER GARY (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:GARY
Last Name:WELLBORN
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 1:624 DIXIE STREET
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3817
Mailing Address - Country:US
Mailing Address - Phone:770-832-9593
Mailing Address - Fax:770-832-0440
Practice Address - Street 1:624 DIXIE STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3817
Practice Address - Country:US
Practice Address - Phone:770-832-9593
Practice Address - Fax:770-832-0440
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00260202AMedicaid
GA00260202AMedicaid