Provider Demographics
NPI:1265848782
Name:VETTIMATTAM, MELANIE (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:VETTIMATTAM
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 1:4230 W GREEN OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-4517
Mailing Address - Country:US
Mailing Address - Phone:817-200-7533
Mailing Address - Fax:817-476-6051
Practice Address - Street 1:4230 W GREEN OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-4517
Practice Address - Country:US
Practice Address - Phone:817-200-7533
Practice Address - Fax:817-476-6051
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR1472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374747902Medicaid
TX374747903Medicaid
TX374747901Medicaid