Provider Demographics
NPI:1972173987
Name:MELTEBEKE, MADISON P (OD)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:P
Last Name:MELTEBEKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-5007
Mailing Address - Country:US
Mailing Address - Phone:503-528-4796
Mailing Address - Fax:
Practice Address - Street 1:1750 MCGILCHRIST ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1691
Practice Address - Country:US
Practice Address - Phone:971-304-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist