Provider Demographics
NPI:1649383787
Name:MELORE, GERALD GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:GEORGE
Last Name:MELORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 SE RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7645
Mailing Address - Country:US
Mailing Address - Phone:360-750-4415
Mailing Address - Fax:
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:COLLEGE OF OPTOMETRY
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116
Practice Address - Country:US
Practice Address - Phone:503-352-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2906 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181549Medicare UPIN