Provider Demographics
NPI:1144257965
Name:MELICHER, KEVIN LYLE (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LYLE
Last Name:MELICHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 13TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3357
Mailing Address - Country:US
Mailing Address - Phone:701-235-3835
Mailing Address - Fax:
Practice Address - Street 1:3902 13TH AVE SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3357
Practice Address - Country:US
Practice Address - Phone:701-282-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDT66906Medicare UPIN
ND0896340001Medicare NSC