Provider Demographics
NPI:1467422584
Name:GOULART, MELISSA A (DO)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:A
Last Name:GOULART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 CEDAR TREE LN
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:KS
Mailing Address - Zip Code:66536-1873
Mailing Address - Country:US
Mailing Address - Phone:785-437-2542
Mailing Address - Fax:
Practice Address - Street 1:206 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:KS
Practice Address - Zip Code:66536-1637
Practice Address - Country:US
Practice Address - Phone:785-437-3734
Practice Address - Fax:785-437-6186
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0530124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100456580AMedicaid
KSG55121Medicare UPIN