Healthcare Provider Details

I. General information

NPI: 1316970262
Provider Name (Legal Business Name): LEONEL P WELCH BASULTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 HIGHWAY 90
BONIFAY FL
32425-6001
US

IV. Provider business mailing address

3269 HIGHWAY 90 EAST
BONIFAY FL
32425-6001
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-9991
  • Fax: 850-547-9992
Mailing address:
  • Phone: 850-547-9991
  • Fax: 850-547-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number201859686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: