Provider Demographics
NPI:1083204317
Name:MCLEMORE, MELINDA LUQUETA (CPT)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:LUQUETA
Last Name:MCLEMORE
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:MS
Other - First Name:MELINDA
Other - Middle Name:LUQUETA
Other - Last Name:MCLEMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPT
Mailing Address - Street 1:40 FOREST GROVE DR APT 9
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1229
Mailing Address - Country:US
Mailing Address - Phone:415-516-6357
Mailing Address - Fax:
Practice Address - Street 1:40 FOREST GROVE DR APT 9
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1229
Practice Address - Country:US
Practice Address - Phone:415-516-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00070917202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology