Provider Demographics
NPI:1528033503
Name:MELICOR, ADOLFO (MD)
Entity Type:Individual
Prefix:
First Name:ADOLFO
Middle Name:
Last Name:MELICOR
Suffix:
Gender:M
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:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-1500
Mailing Address - Country:US
Mailing Address - Phone:248-324-0700
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:24681 NORTHWESTERN HWY
Practice Address - Street 2:STE1
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2305
Practice Address - Country:US
Practice Address - Phone:248-352-2000
Practice Address - Fax:248-352-8800
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010391542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4794406Medicaid
MI4794406Medicaid