Provider Demographics
NPI:1871636639
Name:STULTS, MELISSA ANN (DO)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:STULTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30400 CAMINO CAPISTRANO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1300
Mailing Address - Country:US
Mailing Address - Phone:888-988-2800
Mailing Address - Fax:
Practice Address - Street 1:30400 CAMINO CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1300
Practice Address - Country:US
Practice Address - Phone:888-988-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013955207Q00000X
IL036-104526207Q00000X
CA20A12947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
04527777OtherBCBS
MI1871636639Medicaid
MIM53750095Medicare PIN
MI1871636639Medicaid
H44275Medicare UPIN