Provider Demographics
NPI:1093731812
Name:HARRELL, MELINDA DENISE (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:DENISE
Last Name:HARRELL
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 1:5207 HERITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5915
Mailing Address - Country:US
Mailing Address - Phone:817-355-8000
Mailing Address - Fax:
Practice Address - Street 1:5207 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-355-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1745207Q00000X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R7687OtherBCBS
TX178893703Medicaid
TX8R7687OtherBCBS
TX8R7687OtherBCBS