Provider Demographics
NPI:1861504425
Name:MELTON, MARK RICHARD (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:MELTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 S OTSEGO AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9171
Mailing Address - Country:US
Mailing Address - Phone:989-731-6781
Mailing Address - Fax:989-705-8448
Practice Address - Street 1:1050 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9171
Practice Address - Country:US
Practice Address - Phone:989-731-6781
Practice Address - Fax:989-705-8448
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI87100001Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION