Provider Demographics
NPI:1679527337
Name:WELCH, BENJAMINE MARK (DO)
Entity type:Individual
Prefix:
First Name:BENJAMINE
Middle Name:MARK
Last Name:WELCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:B
Other - Middle Name:MARK
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74018-0368
Mailing Address - Country:US
Mailing Address - Phone:918-342-0137
Mailing Address - Fax:918-342-2304
Practice Address - Street 1:1715 N LYNN RIGGS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3056
Practice Address - Country:US
Practice Address - Phone:918-341-5088
Practice Address - Fax:918-341-5023
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3797207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG68342Medicare UPIN