Provider Demographics
NPI:1508007568
Name:MELANCON, JEFFREY MICHAEL (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:MELANCON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:619-446-1984
Mailing Address - Fax:619-446-1734
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:619-446-1984
Practice Address - Fax:619-446-1734
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA114879207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program