Provider Demographics
NPI:1164715926
Name:FAGONDE, MELISSA TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:TERESA
Last Name:FAGONDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:TERESA
Other - Last Name:FRANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1150 VARNUM ST NE RM 407
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2180
Mailing Address - Country:US
Mailing Address - Phone:202-854-4090
Mailing Address - Fax:202-854-4093
Practice Address - Street 1:1160 VARNUM STREET , NE
Practice Address - Street 2:DEPAUL 110
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-448-4090
Practice Address - Fax:202-448-4093
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD078399207Q00000X
DCMD042650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine