Provider Demographics
NPI:1295832368
Name:MELVILLE, KIRK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:ALAN
Last Name:MELVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1351 STONEBRIDGE PKWY
Mailing Address - Street 2:#106
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6037
Mailing Address - Country:US
Mailing Address - Phone:706-769-0720
Mailing Address - Fax:706-769-8754
Practice Address - Street 1:1351 STONEBRIDGE PKWY
Practice Address - Street 2:#106
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6037
Practice Address - Country:US
Practice Address - Phone:706-769-0720
Practice Address - Fax:706-769-8754
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAA15922Medicare UPIN
GA08BDHXHMedicare ID - Type Unspecified