Provider Demographics
NPI:1477605780
Name:MELTON, MICHAEL GLENN (ABOC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLENN
Last Name:MELTON
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 W 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-3114
Mailing Address - Country:US
Mailing Address - Phone:316-522-2115
Mailing Address - Fax:316-522-9416
Practice Address - Street 1:1016 W 29TH ST S
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-3114
Practice Address - Country:US
Practice Address - Phone:316-522-2115
Practice Address - Fax:316-522-9416
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician