Provider Demographics
NPI:1144560251
Name:BIBICOFF, MELISSA E (DO)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:BIBICOFF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3960 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9200
Mailing Address - Country:US
Mailing Address - Phone:231-947-0404
Mailing Address - Fax:231-947-2190
Practice Address - Street 1:3960 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9200
Practice Address - Country:US
Practice Address - Phone:231-947-0404
Practice Address - Fax:231-947-2190
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101020321207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program