Basic Information
Provider Information | |||||||||
NPI: | 1265464549 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHMELIK | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHMELIK | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1660 S STAPLES ST | ||||||||
Address2: | STE 150 | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784043173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3618008155 | ||||||||
FaxNumber: | 3618822590 | ||||||||
Practice Location | |||||||||
Address1: | 1660 S STAPLES ST | ||||||||
Address2: | STE 150 | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784043173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3618008155 | ||||||||
FaxNumber: | 3618822590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 11/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | M7113 | TX | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207Q00000X | M7113 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | TXB155616 | 01 |   | WELLMED NETWORKS INC | OTHER | TXB150355 | 01 |   | WELLMED MEDICAL GROUP PA | OTHER |