Provider Demographics
NPI:1679836928
Name:WILLEY, MELISSA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:WILLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6418 KINGLET WAY
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-2700
Mailing Address - Country:US
Mailing Address - Phone:760-525-5421
Mailing Address - Fax:
Practice Address - Street 1:2628 GATEWAY RD STE 125
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-1777
Practice Address - Country:US
Practice Address - Phone:760-237-8777
Practice Address - Fax:760-237-8773
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGF826AMedicare UPIN