Provider Demographics
NPI:1629062203
Name:MELTON, STEVENS D (MD)
Entity Type:Individual
Prefix:
First Name:STEVENS
Middle Name:D
Last Name:MELTON
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 1:1700 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-287-4500
Mailing Address - Fax:731-287-4804
Practice Address - Street 1:1700 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-287-4500
Practice Address - Fax:731-287-4804
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD014213208000000X
TN14213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3015669Medicaid
0052428OtherBLUE CROSS
8203648OtherCIGNA
7161OtherTLC (MEMPHIS MANAGED CARE
116249OtherBETTER HEALTH PLAN
1240124OtherUNITED HEALTH CARE
TN4176802OtherBCBS
370008023OtherPALMETTO GBA
4673227OtherAETNA
7161OtherTLC (MEMPHIS MANAGED CARE
1240124OtherUNITED HEALTH CARE
8203648OtherCIGNA