Provider Demographics
NPI:1619677069
Name:WELBORN, SAMUEL CARTER (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CARTER
Last Name:WELBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-0117
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:440-742-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101284363208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice