Provider Demographics
NPI:1538594304
Name:MELVIN, MARK E (HIS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MELVIN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHUMAN BLVD
Mailing Address - Street 2:STE 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8458
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:978-313-6824
Practice Address - Street 1:3832 BAYMEADOWS RD
Practice Address - Street 2:STE 7
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-5607
Practice Address - Country:US
Practice Address - Phone:904-683-6923
Practice Address - Fax:904-683-6936
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 4184237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist