Provider Demographics
NPI:1184773095
Name:WILSON, MELODI LYNETTE (MD)
Entity type:Individual
Prefix:
First Name:MELODI
Middle Name:LYNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2028 OPITZ BLVD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3306
Mailing Address - Country:US
Mailing Address - Phone:703-690-2295
Mailing Address - Fax:703-690-6445
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-391-1500
Practice Address - Fax:703-860-1549
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101235867207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541163152OtherEIN
VA541163152OtherEIN