Provider Demographics
NPI:1205836426
Name:MELANCON, DIANE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:MELANCON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:SCHMITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1687
Mailing Address - Country:US
Mailing Address - Phone:970-256-6322
Mailing Address - Fax:970-263-2691
Practice Address - Street 1:2596 F RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1443
Practice Address - Country:US
Practice Address - Phone:970-254-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0043829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47729732Medicaid
CO47729732Medicaid
CO47729732Medicaid