Provider Demographics
NPI:1578601019
Name:WELLBORN, J. WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:WILLIAM
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:PO BOX 161058
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78716-1058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:800-790-8107
Practice Address - Street 1:9210 SILVER PINE CV
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78733-6122
Practice Address - Country:US
Practice Address - Phone:512-517-7573
Practice Address - Fax:800-790-8107
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1543208100000X
NM85-123208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD69247Medicare UPIN