Provider Demographics
NPI:1639708175
Name:MANTOOTH, MELINDA MAE (DO)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MAE
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4126
Mailing Address - Country:US
Mailing Address - Phone:360-814-2115
Mailing Address - Fax:360-428-2215
Practice Address - Street 1:1415 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4126
Practice Address - Country:US
Practice Address - Phone:360-814-2115
Practice Address - Fax:360-428-2215
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61477654207R00000X
ORDO217033208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine