Provider Demographics
NPI:1558320010
Name:MELICOSTA, MICHELLE ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAINE
Last Name:MELICOSTA
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 1:707 N BROADWAY
Mailing Address - Street 2:KENNEDY KRIEGER INSTITUTE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-1832
Mailing Address - Country:US
Mailing Address - Phone:443-923-9446
Mailing Address - Fax:443-923-9445
Practice Address - Street 1:707 N BROADWAY
Practice Address - Street 2:KENNEDY KRIEGER INSTITUTE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1832
Practice Address - Country:US
Practice Address - Phone:443-923-9446
Practice Address - Fax:443-923-9445
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153384208000000X
MDD0078581208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ970774Medicaid
NM79426778Medicaid
MD541054100Medicaid