Provider Demographics
NPI:1184723132
Name:WELLIVER, ROBERT C (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:WELLIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-2006
Mailing Address - Fax:405-271-2263
Practice Address - Street 1:1200 CHILDRENS AVE
Practice Address - Street 2:OUCPB 5100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-2006
Practice Address - Fax:405-271-2263
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1331122080P0208X, 2080P0204X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000507730005OtherBC OF KANSAS
NY00735837Medicaid
NY040426000753OtherFIDELIS
NY00010187604OtherUNIVERA
NY000507730005OtherBC/BS
NY000507730001OtherBC/BS
NY000507730004OtherBC/BS
NY3905807OtherIHA
000507730004OtherBC OF KANSAS
NY080222000049OtherFIDELIS
000507730005OtherBC OF KANSAS
000507730004OtherBC OF KANSAS