Provider Demographics
NPI:1346246220
Name:MELVILLE, GORDON E (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:E
Last Name:MELVILLE
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 1:579A CRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5426
Mailing Address - Country:US
Mailing Address - Phone:732-390-0040
Mailing Address - Fax:732-390-1856
Practice Address - Street 1:3900 PARK AVE
Practice Address - Street 2:STE 107
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3032
Practice Address - Country:US
Practice Address - Phone:732-548-6800
Practice Address - Fax:732-548-6290
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA046580002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5144302Medicaid
NJ300102255OtherRAILROAD MEDICARE - WARREN
NJ300009505OtherRAILROAD MEDICARE - EDISON
NJ300025888OtherRAILROAD MEDICARE - BRIDGEWATER
NJ300102255OtherRAILROAD MEDICARE - SMC
NJ300102255OtherRAILROAD MEDICARE - SMC
NJ300102255OtherRAILROAD MEDICARE - WARREN