Provider Demographics
NPI:1710044383
Name:MACIAS, MELISSA YVONNE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:YVONNE
Last Name:MACIAS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0067
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:1340 CHARLES ST STE 400
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:815-489-9512
Practice Address - Fax:815-967-5488
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46058020207T00000X
IL036131646207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L17646Medicare PIN