Provider Demographics
NPI:1417335498
Name:BANZON, MELISSA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:BANZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 WHITEHORSE MERCERVILLE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3810
Mailing Address - Country:US
Mailing Address - Phone:095-282-1446
Mailing Address - Fax:
Practice Address - Street 1:1235 WHITEHORSE MERCERVILLE RD STE 301
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3810
Practice Address - Country:US
Practice Address - Phone:609-528-2144
Practice Address - Fax:330-854-0829
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.132627207Q00000X
NJ25MA10877500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0305269Medicaid