Provider Demographics
NPI:1770506297
Name:MEDELLIN, JESSE E
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:E
Last Name:MEDELLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:1200 BROOKLYN AVE
Practice Address - Street 2:SUITE #115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4803
Practice Address - Country:US
Practice Address - Phone:210-224-6531
Practice Address - Fax:210-226-0402
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8253207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01547660OtherRAILROAD MEDICARE
TX118379002Medicaid
TX118379004Medicaid
TX830004821OtherRAILROAD MEDICARE
TX924720OtherAETNA HMO
TX5813027OtherAETNA PPO
TX83Z203OtherBLUECROSS/BLUESHIELD TX.
TX437854YKYCMedicare PIN
TX830004821OtherRAILROAD MEDICARE
TX5813027OtherAETNA PPO