Provider Demographics
NPI:1568877728
Name:MELENDEZ SERRANO, LUIS ARMANDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ARMANDO
Last Name:MELENDEZ SERRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 PARKER ST UNIT 105
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3268
Mailing Address - Country:US
Mailing Address - Phone:787-241-2491
Mailing Address - Fax:
Practice Address - Street 1:525 W ACACIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2405
Practice Address - Country:US
Practice Address - Phone:209-242-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR31705-R390200000X
CAA151303207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty