Provider Demographics
NPI:1417375528
Name:ITSARA, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ITSARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 HEALTH SCIENCE DRIVE
Mailing Address - Street 2:SUITE 6510
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:530-752-2884
Mailing Address - Fax:530-754-6047
Practice Address - Street 1:451 HEALTH SCIENCE DRIVE
Practice Address - Street 2:SUITE 6510
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-752-2884
Practice Address - Fax:530-754-6047
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140042207R00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine