Healthcare Provider Details

I. General information

NPI: 1881677516
Provider Name (Legal Business Name): KATHERINE M WELTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 W WARREN AVE STE 100
LONGWOOD FL
32750-4036
US

IV. Provider business mailing address

12395 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-6217
US

V. Phone/Fax

Practice location:
  • Phone: 407-438-8840
  • Fax: 407-438-8893
Mailing address:
  • Phone: 407-438-8840
  • Fax: 407-438-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0068336
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME68336
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: