Provider Demographics
NPI:1184735672
Name:WELSH, KENNETH W (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:WELSH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N ALVERNON WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1958
Mailing Address - Country:US
Mailing Address - Phone:520-327-6215
Mailing Address - Fax:520-327-6546
Practice Address - Street 1:101 S LA CANADA DR STE 69
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2665
Practice Address - Country:US
Practice Address - Phone:520-625-5657
Practice Address - Fax:520-625-5659
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ036782Medicaid
AZ29907Medicare ID - Type Unspecified
AZU16537Medicare UPIN