Provider Demographics
NPI:1164093886
Name:MELVIN, DOMINIQUE D
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:D
Last Name:MELVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36171
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95158-6171
Mailing Address - Country:US
Mailing Address - Phone:408-833-4778
Mailing Address - Fax:408-899-5512
Practice Address - Street 1:4563 LYNFIELD LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95136-1627
Practice Address - Country:US
Practice Address - Phone:408-833-9585
Practice Address - Fax:408-899-5512
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver