Provider Demographics
NPI:1518175579
Name:AGOUDEMOS, MELISSA M M (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M M
Last Name:AGOUDEMOS
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 1:520 S EAGLE RD
Mailing Address - Street 2:SUITE 2204
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-336-9188
Mailing Address - Fax:208-336-2636
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 2204
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-336-9188
Practice Address - Fax:208-336-2636
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8001208000000X
IL036-1254472080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125447Medicaid
IL256510073Medicare PIN