Provider Demographics
NPI:1750499067
Name:BREITLING, MELISSA A (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BREITLING
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:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0001
Mailing Address - Country:US
Mailing Address - Phone:901-488-8583
Mailing Address - Fax:662-393-8819
Practice Address - Street 1:3102 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1172
Practice Address - Country:US
Practice Address - Phone:662-342-6677
Practice Address - Fax:662-393-8819
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17459207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F69417Medicare UPIN