Provider Demographics
NPI:1710910294
Name:FREDERIKSE, MELISSA ELLISON (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELLISON
Last Name:FREDERIKSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MILLBURN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1737
Mailing Address - Country:US
Mailing Address - Phone:973-218-1511
Mailing Address - Fax:973-218-1477
Practice Address - Street 1:225 MILLBURN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1737
Practice Address - Country:US
Practice Address - Phone:973-218-1511
Practice Address - Fax:973-218-1477
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA069495002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8148007Medicaid
G03601Medicare UPIN
NJ035789Medicare ID - Type Unspecified