Provider Demographics
NPI:1659419208
Name:FARIAS HUTTON, MELINDA ROSE
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:ROSE
Last Name:FARIAS HUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14601 RED RIVER DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-5624
Mailing Address - Country:US
Mailing Address - Phone:361-726-5801
Mailing Address - Fax:361-241-7613
Practice Address - Street 1:14601 RED RIVER DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-5624
Practice Address - Country:US
Practice Address - Phone:361-726-5801
Practice Address - Fax:361-241-7613
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32004747419332B00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32004747419OtherTAXPAYER ID