Provider Demographics
NPI:1528006590
Name:KRAFT, MELANIE SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:SUSAN
Last Name:KRAFT
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 1:4500 S 102ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-4813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 S 102ND EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-4813
Practice Address - Country:US
Practice Address - Phone:918-627-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104143207Q00000X
OK21010207Q00000X
KS04-27866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203874268Medicaid
KS200000600 AMedicaid
KS200000600BMedicaid
OK200237300AMedicaid
MOP00105055Medicare ID - Type UnspecifiedRAILROAD MEDICARE-GOPPERT
KS200000600 AMedicaid
MOG86175Medicare UPIN
OK200237300AMedicaid