Healthcare Provider Details

I. General information

NPI: 1962709733
Provider Name (Legal Business Name): ETHAN LEO WELCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 ADMIRALTY WAY
WEBSTER NY
14580-3904
US

IV. Provider business mailing address

656 ADMIRALTY WAY
WEBSTER NY
14580-3904
US

V. Phone/Fax

Practice location:
  • Phone: 585-787-0055
  • Fax:
Mailing address:
  • Phone: 585-787-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number81770
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number81770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: