Provider Demographics
NPI:1417043233
Name:CLIFFORD RALPH MELTON
Entity Type:Organization
Organization Name:CLIFFORD RALPH MELTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-835-3680
Mailing Address - Street 1:401 29TH ST
Mailing Address - Street 2:206
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-835-3680
Mailing Address - Fax:510-835-0738
Practice Address - Street 1:401 29TH ST
Practice Address - Street 2:206
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-835-3680
Practice Address - Fax:510-835-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35741208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A357410Medicaid
CA00A357410Medicaid
A27891Medicare UPIN