Provider Demographics
NPI:1255498192
Name:MELENEVSKAYA, SOFIA B (MD)
Entity Type:Individual
Prefix:DR
First Name:SOFIA
Middle Name:B
Last Name:MELENEVSKAYA
Suffix:
Gender:F
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:PO BOX 59037
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459
Mailing Address - Country:US
Mailing Address - Phone:853-301-9842
Mailing Address - Fax:
Practice Address - Street 1:319 ALLSTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-734-1300
Practice Address - Fax:617-734-1330
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48371174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3009424Medicaid
MAJ05609Medicare ID - Type Unspecified
MA3009424Medicaid