Provider Demographics
NPI:1740693829
Name:WELBORN, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WELBORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6436
Mailing Address - Country:US
Mailing Address - Phone:432-203-0201
Mailing Address - Fax:
Practice Address - Street 1:2501 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6436
Practice Address - Country:US
Practice Address - Phone:432-203-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1200656208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation