Basic Information
Provider Information | |||||||||
NPI: | 1497958995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELTER | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3418 MIDCOURT RD | ||||||||
Address2: | STE 118 | ||||||||
City: | CARROLLTON | ||||||||
State: | TX | ||||||||
PostalCode: | 750065073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144208200 | ||||||||
FaxNumber: | 2144208205 | ||||||||
Practice Location | |||||||||
Address1: | 3418 MIDCOURT RD | ||||||||
Address2: | STE 118 | ||||||||
City: | CARROLLTON | ||||||||
State: | TX | ||||||||
PostalCode: | 750065073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144208200 | ||||||||
FaxNumber: | 2144208205 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2007 | ||||||||
LastUpdateDate: | 01/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207ZP0101X | M6950 | TX | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
ID | Type | State | Issuer | Description | BP1-0018049 | 01 |   | INSTITUTIONAL PERMIT | OTHER | M6950 | 01 | TX | STATE LICENCE | OTHER |