Basic Information
| Provider Information | |||||||||
| NPI: | 1184723132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLIVER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 236 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712006 | ||||||||
| FaxNumber: | 4052712263 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 CHILDRENS AVE | ||||||||
| Address2: | OUCPB 5100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731044637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712006 | ||||||||
| FaxNumber: | 4052712263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 133112 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 2080P0204X | 133112 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080P0210X | 133112 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 000507730005 | 01 | BC OF KANSAS | OTHER | 00735837 | 05 | NY | MEDICAID | 040426000753 | 01 | NY | FIDELIS | OTHER | 00010187604 | 01 | NY | UNIVERA | OTHER | 000507730005 | 01 | NY | BC/BS | OTHER | 000507730001 | 01 | NY | BC/BS | OTHER | 000507730004 | 01 | NY | BC/BS | OTHER | 3905807 | 01 | NY | IHA | OTHER | 000507730004 | 01 | BC OF KANSAS | OTHER | 080222000049 | 01 | NY | FIDELIS | OTHER |