Provider Demographics
NPI:1992185763
Name:GONZALEZ, MELANIE (DPM)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 E R D MIZE R.D. STE B
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057
Mailing Address - Country:US
Mailing Address - Phone:816-478-3338
Mailing Address - Fax:
Practice Address - Street 1:2406 E R.D. MIZE RD STE. B
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-6405
Practice Address - Country:US
Practice Address - Phone:816-478-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018032267213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992185763Medicaid