Provider Demographics
NPI:1710083852
Name:MELTON, LAURI ANDERWALD (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURI
Middle Name:ANDERWALD
Last Name:MELTON
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 1:1004 KELLER PARKWAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248
Mailing Address - Country:US
Mailing Address - Phone:817-431-3937
Mailing Address - Fax:
Practice Address - Street 1:1004 KELLER PARKWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248
Practice Address - Country:US
Practice Address - Phone:817-431-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80851Medicare UPIN
00933EMedicare ID - Type Unspecified