Provider Demographics
NPI:1235180225
Name:DACUMOS, MELISSA ANNE (OD)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:ANNE
Last Name:DACUMOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:DACUMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-748-8632
Mailing Address - Fax:360-748-3869
Practice Address - Street 1:2915 S ALDER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4803
Practice Address - Country:US
Practice Address - Phone:253-473-0275
Practice Address - Fax:253-473-0706
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-815152W00000X
WAOD00003971152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1005577Medicaid
WAG8893416OtherMEDICARE WA
MT011003797OtherMEDICARE MT
WAG8885650OtherMEDICARE WA
WA2030963Medicaid
WA8866626Medicare PIN
WAG8866627Medicare PIN
WAG8866629Medicare PIN