1205075116 NPI number — MELONIE C PROCTOR DO

Table of content: MELONIE C PROCTOR DO (NPI 1205075116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205075116 NPI number — MELONIE C PROCTOR DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCTOR
Provider First Name:
MELONIE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205075116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 635283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-5283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-301-7210
Provider Business Mailing Address Fax Number:
859-301-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1808 BRISTOW DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41091-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-301-7210
Provider Business Practice Location Address Fax Number:
859-301-7216
Provider Enumeration Date:
02/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R1572 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 03181 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3110270 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00856623 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100135290 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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