1831235662 NPI number — DR. JEFFREY DAVID MELICHER O.D.

Table of content: DR. JEFFREY DAVID MELICHER O.D. (NPI 1831235662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831235662 NPI number — DR. JEFFREY DAVID MELICHER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELICHER
Provider First Name:
JEFFREY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1831235662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4369 OLAUGHLIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVELETH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55734-4029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-744-3288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5465 MOUNTAIN IRON DR
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
VIRGINIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55792-3372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-741-3000
Provider Business Practice Location Address Fax Number:
218-741-0800
Provider Enumeration Date:
01/29/2007

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: 152W00000X , with the licence number:  2409 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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