Provider Demographics
NPI:1447236922
Name:MELVIN, KELLI P (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:P
Last Name:MELVIN
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 1:1012 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-2556
Mailing Address - Country:US
Mailing Address - Phone:937-866-0741
Mailing Address - Fax:937-866-8861
Practice Address - Street 1:3033 KETTERING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1962
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:937-866-8861
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8234201OtherHUMANA
OH7082442OtherAETNA
OH2461232Medicaid
OH283160OtherAMERIGROUP
OH2461232Medicaid
OH4117371Medicare ID - Type Unspecified