Provider Demographics
NPI:1255447074
Name:WELCH, GUSTIN MACKAY (DO)
Entity type:Individual
Prefix:DR
First Name:GUSTIN
Middle Name:MACKAY
Last Name:WELCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2335
Mailing Address - Country:US
Mailing Address - Phone:706-257-7200
Mailing Address - Fax:
Practice Address - Street 1:1310 13TH AVENUE
Practice Address - Street 2:VA COBC
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-257-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO614207Q00000X
GA371052083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G95336Medicare UPIN