Provider Demographics
NPI:1205935590
Name:DERRO, MELANIO M (MD)
Entity type:Individual
Prefix:DR
First Name:MELANIO
Middle Name:M
Last Name:DERRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CHAMBERS RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9293
Mailing Address - Country:US
Mailing Address - Phone:989-673-3191
Mailing Address - Fax:989-673-0064
Practice Address - Street 1:2000 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9293
Practice Address - Country:US
Practice Address - Phone:989-673-3191
Practice Address - Fax:989-673-0064
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301401337207Q00000X
WV17095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G96037OtherMEDICARE PART B
MI1758845Medicaid
MI234025OtherMEDICARE PART A
MI1758845Medicaid