Provider Demographics
NPI:1023104536
Name:MELNYCHUK, IGOR (MD)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:MELNYCHUK
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:P.O. BOX 16292
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245
Mailing Address - Country:US
Mailing Address - Phone:904-352-2466
Mailing Address - Fax:904-352-2472
Practice Address - Street 1:14546 OLD ST AUGUSTINE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-352-2466
Practice Address - Fax:904-352-2472
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88142207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268770401Medicaid
FLH98619Medicare UPIN
FL268770401Medicaid