Provider Demographics
NPI:1942566534
Name:CHANDOU, MELAINA (DO)
Entity Type:Individual
Prefix:
First Name:MELAINA
Middle Name:
Last Name:CHANDOU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELAINA
Other - Middle Name:
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-1200
Practice Address - Fax:217-223-9945
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9314207P00000X
IL036141450207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400323814Medicare UPIN