Basic Information
| Provider Information | |||||||||
| NPI: | 1700880648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELCH | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | CALDERON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALDERON | ||||||||
| OtherFirstName: | MARLENE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6525 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | LAMBERTVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481449431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795897 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 05/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 35084562 | OH | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2489472 | 05 | OH | MEDICAID |