Provider Demographics
NPI:1093754780
Name:MELNICK, SIMON (DO)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:MELNICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-6009
Mailing Address - Country:US
Mailing Address - Phone:508-324-3550
Mailing Address - Fax:508-676-5671
Practice Address - Street 1:400 STANLEY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-6009
Practice Address - Country:US
Practice Address - Phone:508-675-1054
Practice Address - Fax:508-324-7777
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00518207Q00000X, 208D00000X
MA270103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007056540Medicaid
RI709003425Medicare ID - Type UnspecifiedGROUP
RI007056540Medicaid