Provider Demographics
NPI:1225143142
Name:MELTON, JACK FORREST (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:FORREST
Last Name:MELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4708 ALLIANCE BLVD STE 300
Mailing Address - Street 2:BAYLOR MEDICAL PLAZA 1
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5339
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD STE 300
Practice Address - Street 2:BAYLOR MEDICAL PLAZA 1
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5339
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3633207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83X010OtherBCBS
TX8B9896Medicare PIN
TX110097139Medicare PIN
TX83X010OtherBCBS