Provider Demographics
NPI:1104188390
Name:THOMPSON, MELANIE ROSE (DO)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ROSE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:ROSE
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6090 REDWOOD BLVD G
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-4569
Mailing Address - Country:US
Mailing Address - Phone:415-798-3106
Mailing Address - Fax:415-798-3180
Practice Address - Street 1:155 N FRESNO ST
Practice Address - Street 2:ATTN: FAMILY MEDICINE
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2302
Practice Address - Country:US
Practice Address - Phone:559-499-6450
Practice Address - Fax:559-499-6451
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine