Provider Demographics
NPI:1679559322
Name:MELSTROM, RICHARD THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:MELSTROM
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 1:118 STIMSON ST
Mailing Address - Street 2:PO BOX 409
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2238
Mailing Address - Country:US
Mailing Address - Phone:231-775-6031
Mailing Address - Fax:
Practice Address - Street 1:118 STIMSON ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2238
Practice Address - Country:US
Practice Address - Phone:231-775-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5028837Medicaid
MIT33808Medicare UPIN
MI0H36504Medicare ID - Type UnspecifiedMEDICARE