Provider Demographics
NPI:1912966748
Name:WELK, GORDON DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:DANIEL
Last Name:WELK
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-446-7023
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025175A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000189493OtherUC ANTHEM PROVIDER NUMBER
IN000000341035OtherFP ANTHEM PROVIDER NUMBER
IN10826167OtherCAQH NUMBER
IN100117190Medicaid
IN9038773OtherPHCS PID NUMBER
IN000000189493OtherUC ANTHEM PROVIDER NUMBER
IN199190HMedicare PIN
IN080121478Medicare PIN
IN142080HHMedicare PIN
IN921480WMedicare PIN
IN815500CCCMedicare PIN
IN10826167OtherCAQH NUMBER
IN100117190Medicaid