Provider Demographics
NPI:1144286410
Name:WILLINGHAM, MELINDA A (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:A
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:A
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2321 HENRY CLOWER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7419
Mailing Address - Country:US
Mailing Address - Phone:404-842-5070
Mailing Address - Fax:626-741-0963
Practice Address - Street 1:2321 HENRY CLOWER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7419
Practice Address - Country:US
Practice Address - Phone:404-842-5070
Practice Address - Fax:626-741-0963
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00791458KMedicaid
GA000791458EMedicaid
GA000791458CMedicaid
GA00791458KMedicaid