Provider Demographics
NPI:1790049641
Name:WELLBAUM, KEVIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:WELLBAUM
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:656 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2538
Practice Address - Country:US
Practice Address - Phone:704-664-5133
Practice Address - Fax:704-660-0406
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5536208000000X
GA074135208000000X
NC2016-01403208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics