Provider Demographics
NPI:1013906577
Name:COOMBS-BYNUM, MELANIE ALIZA (MD)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ALIZA
Last Name:COOMBS-BYNUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:A
Other - Last Name:COOMBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-481-5437
Practice Address - Fax:239-481-0570
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78142208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256893400Medicaid