Basic Information
| Provider Information | |||||||||
| NPI: | 1770506297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDELLIN | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 BROOKLYN AVE | ||||||||
| Address2: | SUITE #115 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102246531 | ||||||||
| FaxNumber: | 2102260402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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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 | 207RH0003X | H8253 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | P01547660 | 01 | TX | RAILROAD MEDICARE | OTHER | 118379002 | 05 | TX | MEDICAID | 118379004 | 05 | TX | MEDICAID | 830004821 | 01 | TX | RAILROAD MEDICARE | OTHER | 924720 | 01 | TX | AETNA HMO | OTHER | 5813027 | 01 | TX | AETNA PPO | OTHER | 83Z203 | 01 | TX | BLUECROSS/BLUESHIELD TX. | OTHER |