Basic Information
| Provider Information | |||||||||
| NPI: | 1184626871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDELLIN | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 SAINT GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 SAINT GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H9467 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | H9467 | 01 | TX | TEXAS STATE LICENSE | OTHER | 128480406 | 05 | TX | MEDICAID |