Provider Demographics
NPI:1326021486
Name:MELTON, RUSSELL W (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:W
Last Name:MELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 MEMORIAL AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2652
Mailing Address - Country:US
Mailing Address - Phone:434-200-5200
Mailing Address - Fax:
Practice Address - Street 1:2323 MEMORIAL AVE STE 10
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2652
Practice Address - Country:US
Practice Address - Phone:434-200-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-055801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005646847Medicaid
VA005646944Medicaid
VA017932C18Medicare PIN
VA005646847Medicaid
VA005646944Medicaid