Provider Demographics
NPI:1144229451
Name:MELIDONA, MARIO (PT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MELIDONA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4188 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-1134
Mailing Address - Country:US
Mailing Address - Phone:585-243-9150
Mailing Address - Fax:585-243-4814
Practice Address - Street 1:4188 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1134
Practice Address - Country:US
Practice Address - Phone:585-243-9150
Practice Address - Fax:585-243-4814
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
NY010148174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist