Provider Demographics
NPI:1386676039
Name:PARK, MELISSA LEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LEE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LEE
Other - Last Name:BROOMHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:1203 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1940
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015943207R00000X
IDM-10546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431898000Medicaid
ID808286200Medicaid
ID1100481Medicare PIN
ID808286200Medicaid
ME431898000Medicaid
P00714056Medicare PIN