Provider Demographics
NPI:1467433953
Name:MELVIN, ELLEN THERESE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:THERESE
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 1:3675 20TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2480
Mailing Address - Country:US
Mailing Address - Phone:772-569-6869
Mailing Address - Fax:772-569-8214
Practice Address - Street 1:3675 20TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2480
Practice Address - Country:US
Practice Address - Phone:772-569-6869
Practice Address - Fax:772-569-8214
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC05785Medicare UPIN
FLK1881Medicare ID - Type UnspecifiedMEDICARE ID