Provider Demographics
NPI:1073536074
Name:ELENDU, SEBASTINE I (MD)
Entity Type:Individual
Prefix:
First Name:SEBASTINE
Middle Name:I
Last Name:ELENDU
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 1:1559 208TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-638-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA199938207R00000X
SC32334207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1134Medicaid
SCGP4306OtherMEDICAID GROUP
LA1076350Medicaid
MS02053740Medicaid
SCGP3912OtherMEDICAID GROUP
LA1076350Medicaid
MS02053740Medicaid
SCNC1134Medicaid
SCAA54547153Medicare PIN