Healthcare Provider Details

I. General information

NPI: 1275622110
Provider Name (Legal Business Name): DARA J WELBORN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S EASTERN AVE SUITE 309
HENDERSON NV
89052-3907
US

IV. Provider business mailing address

10001 S EASTERN AVE SUITE 309
HENDERSON NV
89052-3907
US

V. Phone/Fax

Practice location:
  • Phone: 702-269-6346
  • Fax: 702-269-9422
Mailing address:
  • Phone: 702-269-6345
  • Fax: 702-269-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10216
License Number StateNV

VIII. Authorized Official

Name: DARA WELBORN
Title or Position: PRESIDENT
Credential: MD
Phone: 702-269-6345