Provider Demographics
NPI:1366632523
Name:SKELLY, CYNTHIA DANIELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:DANIELLE
Last Name:SKELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-6902
Mailing Address - Country:US
Mailing Address - Phone:386-213-2879
Mailing Address - Fax:
Practice Address - Street 1:10321 N 2274 RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-7521
Practice Address - Country:US
Practice Address - Phone:580-331-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL102664208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000130400Medicaid