Provider Demographics
NPI:1235123399
Name:MELAMED, YITZHAK A (MD)
Entity Type:Individual
Prefix:
First Name:YITZHAK
Middle Name:A
Last Name:MELAMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 WESTFORK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1544
Mailing Address - Country:US
Mailing Address - Phone:770-941-5552
Mailing Address - Fax:770-941-2289
Practice Address - Street 1:1515 WESTFORK DR
Practice Address - Street 2:SUITE C
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1544
Practice Address - Country:US
Practice Address - Phone:770-941-5552
Practice Address - Fax:770-941-2289
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38305208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000618659DMedicaid