Provider Demographics
NPI:1518926393
Name:MELENDEZ, ELIEZER (MD)
Entity type:Individual
Prefix:DR
First Name:ELIEZER
Middle Name:
Last Name:MELENDEZ
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:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8383
Mailing Address - Fax:707-263-5019
Practice Address - Street 1:925 BEVINS COURT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315008496208000000X
CA195676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104358918Medicaid
MIS18890Medicare UPIN
MI0G56212012Medicare PIN
MI104358918Medicaid