Provider Demographics
NPI:1679560767
Name:WELTON, TIMOTHY HERSHEL (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:HERSHEL
Last Name:WELTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W LINCOLN AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-2936
Mailing Address - Country:US
Mailing Address - Phone:714-535-8404
Mailing Address - Fax:714-687-9848
Practice Address - Street 1:303 W LINCOLN AVE
Practice Address - Street 2:STE 120
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-2936
Practice Address - Country:US
Practice Address - Phone:714-535-8404
Practice Address - Fax:714-687-9848
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10177 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101770Medicaid
CASD0101770Medicaid
CAWY059Medicare ID - Type Unspecified