Provider Demographics
NPI:1780647263
Name:MAILLOUX, MELANIE ANN (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:MAILLOUX
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 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MS 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:5433 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1382
Practice Address - Country:US
Practice Address - Phone:414-277-8900
Practice Address - Fax:414-277-8939
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231620208000000X
WI53698-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903026Medicaid
VA010217504Medicaid
WI1780647263Medicaid
WI1780647263Medicaid
VA010217504Medicaid