Provider Demographics
NPI:1962709733
Name:WELCH, ETHAN LEO (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:LEO
Last Name:WELCH
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 1:656 ADMIRALTY WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-3904
Mailing Address - Country:US
Mailing Address - Phone:585-787-0055
Mailing Address - Fax:
Practice Address - Street 1:656 ADMIRALTY WAY
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-3904
Practice Address - Country:US
Practice Address - Phone:585-787-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY81770174400000X, 1744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No1744R1102XOther Service ProvidersSpecialistResearch Study
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY81770OtherNEW YORK STATE LICENSE