Healthcare Provider Details

I. General information

NPI: 1144208331
Provider Name (Legal Business Name): MARK JOHN WELTER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
U S A F ACADEMY CO
80840-2502
US

IV. Provider business mailing address

919 TARI DR
COLORADO SPRINGS CO
80921-2256
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-7921
  • Fax:
Mailing address:
  • Phone: 719-484-0241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3105
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: