Provider Demographics
NPI:1275575664
Name:MELNICZEK, DAVID MYATT (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MYATT
Last Name:MELNICZEK
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:777 S STATE HIGHWAY 49 STE 1&2
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2685
Mailing Address - Country:US
Mailing Address - Phone:209-256-8200
Mailing Address - Fax:209-256-8204
Practice Address - Street 1:777 S STATE HIGHWAY 49 STE 1&2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2685
Practice Address - Country:US
Practice Address - Phone:209-256-8200
Practice Address - Fax:209-256-8204
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA92447208600000X
PAMD434501208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92447OtherLICENSE