Provider Demographics
NPI:1922065812
Name:MELTON, LARRY B (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:B
Last Name:MELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BAXTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1823
Mailing Address - Country:US
Mailing Address - Phone:207-662-7180
Mailing Address - Fax:
Practice Address - Street 1:1600 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2143
Practice Address - Country:US
Practice Address - Phone:207-662-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD25258207RN0300X
COCDRH.0062397207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122724103Medicaid
NM88182053Medicaid
CO9000201221Medicaid
TX390003278Medicare PIN