Provider Demographics
NPI:1013080787
Name:MELENDEZ, MICHAEL GERARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GERARDO
Last Name:MELENDEZ
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 1:2789 E SPYGLASS CT
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-762-0288
Mailing Address - Fax:208-777-1313
Practice Address - Street 1:2789 E SPYGLASS CT
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815
Practice Address - Country:US
Practice Address - Phone:208-610-0041
Practice Address - Fax:208-777-1313
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-37552085R0202X
UT160913-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8111379Medicaid
WA8111379Medicaid
B63618Medicare UPIN