Provider Demographics
NPI:1760478259
Name:WELLBORN, COLVIN CLAY (MD)
Entity Type:Individual
Prefix:
First Name:COLVIN
Middle Name:CLAY
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 1:1715 N GEORGE MASON DR
Mailing Address - Street 2:#504
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3609
Mailing Address - Country:US
Mailing Address - Phone:703-525-2200
Mailing Address - Fax:703-522-2603
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:#504
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-525-2200
Practice Address - Fax:703-522-2603
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84666207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G846660Medicaid
CAG84666Medicare ID - Type Unspecified