Provider Demographics
NPI:1518948223
Name:MELMED, JACK PAUL (OPTOMETRIST)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PAUL
Last Name:MELMED
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-4324
Mailing Address - Country:US
Mailing Address - Phone:323-566-6183
Mailing Address - Fax:323-566-0319
Practice Address - Street 1:3329 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-4324
Practice Address - Country:US
Practice Address - Phone:323-566-6183
Practice Address - Fax:323-566-0319
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY152OtherMEDICARE PTAN
CAT09743Medicare UPIN
CAWY152OtherMEDICARE PTAN