Provider Demographics
NPI:1467575738
Name:MELGOSA, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:MELGOSA
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 1:5535
Mailing Address - Street 2:KINGSWOOD STREET
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228
Mailing Address - Country:US
Mailing Address - Phone:210-433-7527
Mailing Address - Fax:
Practice Address - Street 1:5535 KINGSWOOD ST
Practice Address - Street 2:KINGSWOOD STREET
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-3520
Practice Address - Country:US
Practice Address - Phone:210-433-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250764163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics