Provider Demographics
NPI:1386674273
Name:BLAKE-BETHEA, MELROSE (DPM)
Entity Type:Individual
Prefix:
First Name:MELROSE
Middle Name:
Last Name:BLAKE-BETHEA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 CHANCELLOR AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2955
Mailing Address - Country:US
Mailing Address - Phone:973-375-5882
Mailing Address - Fax:973-371-7990
Practice Address - Street 1:774 CHANCELLOR AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-2955
Practice Address - Country:US
Practice Address - Phone:973-375-5882
Practice Address - Fax:973-371-7990
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00228700213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MD00228700OtherPODIATRY LICENSE
NJDO7146200OtherCDS PODIATRY