Provider Demographics
NPI:1912028861
Name:MELICIEN TETTAMBEL, D.O., S.C.
Entity Type:Organization
Organization Name:MELICIEN TETTAMBEL, D.O., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MELICIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TETTAMBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-627-5175
Mailing Address - Street 1:1108 E PATTERSON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4002
Mailing Address - Country:US
Mailing Address - Phone:660-627-5175
Mailing Address - Fax:660-627-5180
Practice Address - Street 1:1108 E PATTERSON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4002
Practice Address - Country:US
Practice Address - Phone:660-627-5175
Practice Address - Fax:660-627-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9714204D00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC48040Medicare UPIN