Provider Demographics
NPI:1063486157
Name:KAVADELLA, MELPOMENI G (MD)
Entity Type:Individual
Prefix:
First Name:MELPOMENI
Middle Name:G
Last Name:KAVADELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9310 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7822
Mailing Address - Country:US
Mailing Address - Phone:231-935-0355
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY
Practice Address - Street 2:SUITE #200
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9558
Practice Address - Country:US
Practice Address - Phone:231-882-2168
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4208349Medicaid
MI4301407649OtherSTATE LICENSE NUMBER
MIMK407649Other3RD PARTY IDENTIFIER
MIMK407649Other3RD PARTY IDENTIFIER
MI4208349Medicaid