Provider Demographics
NPI:1912096363
Name:WELCH, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2824
Mailing Address - Country:US
Mailing Address - Phone:404-289-1952
Mailing Address - Fax:404-289-1953
Practice Address - Street 1:1290 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2824
Practice Address - Country:US
Practice Address - Phone:404-289-1952
Practice Address - Fax:404-289-1953
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG36311Medicare UPIN
GA102I118998Medicare PIN