Provider Demographics
NPI:1003882978
Name:ICASIANO, MELODIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MELODIE
Middle Name:M
Last Name:ICASIANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:100 LANCASTER AVE
Mailing Address - Street 2:MOB EAST SUITE 158
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3427
Mailing Address - Country:US
Mailing Address - Phone:610-649-2126
Mailing Address - Fax:610-642-7814
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:BLDG 9040 FITZSIMMONS DR.
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00042886207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology