Provider Demographics
NPI:1891399150
Name:MEDELLIN, ELIWID SIERRA
Entity Type:Individual
Prefix:
First Name:ELIWID
Middle Name:SIERRA
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 1:1807 N HARTFORD ST APT 511
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-5755
Mailing Address - Country:US
Mailing Address - Phone:918-207-8950
Mailing Address - Fax:
Practice Address - Street 1:1624 CIMARRON PLZ
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3467
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:405-445-3780
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator