Provider Demographics
NPI:1679645881
Name:WELTY JR, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:WELTY JR
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 1:1520 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2698
Mailing Address - Country:US
Mailing Address - Phone:937-228-5115
Mailing Address - Fax:937-228-4591
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-228-5115
Practice Address - Fax:937-228-4591
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350448242086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0777268Medicaid
OHWE0552341Medicare ID - Type Unspecified
OH0777268Medicaid