Provider Demographics
NPI:1457005514
Name:MELKUMIAN, MARIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MELKUMIAN
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 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8408
Mailing Address - Country:US
Mailing Address - Phone:631-894-5943
Mailing Address - Fax:631-206-9306
Practice Address - Street 1:3754 W DIVERSEY AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1160
Practice Address - Country:US
Practice Address - Phone:630-386-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000668246ZC0007X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant