Provider Demographics
NPI:1952601031
Name:WELD, KENNETH T
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:T
Last Name:WELD
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 1:2345 JAINE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-4200
Mailing Address - Country:US
Mailing Address - Phone:707-225-1471
Mailing Address - Fax:
Practice Address - Street 1:6340 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2404
Practice Address - Country:US
Practice Address - Phone:707-585-5980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist