Healthcare Provider Details

I. General information

NPI: 1255447074
Provider Name (Legal Business Name): GUSTIN MACKAY WELCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 13TH AVENUE VA COBC
COLUMBUS GA
31901
US

IV. Provider business mailing address

1310 13TH AVE
COLUMBUS GA
31901-2335
US

V. Phone/Fax

Practice location:
  • Phone: 706-257-7205
  • Fax:
Mailing address:
  • Phone: 706-257-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO614
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number37105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: