Provider Demographics
NPI:1619176955
Name:MACLENNAN, MELANIE (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MACLENNAN
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 1:198 E 7TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-5956
Mailing Address - Country:US
Mailing Address - Phone:917-687-5334
Mailing Address - Fax:
Practice Address - Street 1:198 E 7TH ST APT 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-5956
Practice Address - Country:US
Practice Address - Phone:917-687-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-01201207Q00000X
SCT3025207Q00000X
NY206178-1207Q00000X
NY206178207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2148685Medicaid