Provider Demographics
NPI:1750448981
Name:MELINA, CARL M (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:M
Last Name:MELINA
Suffix:
Gender:M
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:18610 NW CORNELL ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9923
Practice Address - Country:US
Practice Address - Phone:503-216-9360
Practice Address - Fax:503-216-9363
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3948207PE0004X
ORMD28596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010004964OtherREGENCE BS ID
ID003843600Medicaid
WA8167140Medicaid
IDB1725OtherBLUE CROSS ID
OR024599Medicaid
ID080062808OtherRAILRAOD
ORP00650735OtherRR MEDICARE
ORR147004Medicare PIN
ORP00650735OtherRR MEDICARE
WA8167140Medicaid
ID003843600Medicaid
ORR155234Medicare PIN
ORR158483Medicare PIN
ID00010004964OtherREGENCE BS ID
IDB1725OtherBLUE CROSS ID
ORR143630Medicare PIN
ORR157224Medicare PIN