Provider Demographics
NPI:1558373530
Name:WELCH, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WELCH
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:1515 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4244
Practice Address - Country:US
Practice Address - Phone:601-425-4893
Practice Address - Fax:601-428-8633
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05861207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05107231Medicaid
MSP00300448OtherRAILROAD MEDICARE
MS080004194Medicare ID - Type Unspecified
MS05107231Medicaid