Provider Demographics
NPI:1346766060
Name:BOURLAND, MELISSA DAWN (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:BOURLAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 IVY LN
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1348
Mailing Address - Country:US
Mailing Address - Phone:219-381-7208
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1200
Practice Address - Country:US
Practice Address - Phone:219-322-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004066A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist