Provider Demographics
NPI:1881677979
Name:MELVIN, LISSA M (MD)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:M
Last Name:MELVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:K
Other - Last Name:MAGLOIRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5414 FREDERICKSBURG RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-2209
Mailing Address - Fax:210-614-5714
Practice Address - Street 1:5414 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-2209
Practice Address - Fax:210-614-5714
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042041207V00000X
TXM6738207VG0400X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1867277-01Medicaid
CT001420413Medicaid
TX1867277-01Medicaid
CT160002194Medicare ID - Type Unspecified