Provider Demographics
NPI:1760543177
Name:JACK, MELINDA KRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:KRISTINE
Last Name:JACK
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 1:5965 E BROAD ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1562
Mailing Address - Country:US
Mailing Address - Phone:614-864-1000
Mailing Address - Fax:614-864-1444
Practice Address - Street 1:5965 E BROAD ST
Practice Address - Street 2:SUITE 120
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1562
Practice Address - Country:US
Practice Address - Phone:614-864-1000
Practice Address - Fax:614-864-1444
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35088654208600000X
OH35-088654208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery