Provider Demographics
NPI:1245316082
Name:VISSER, MELODYE ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:MELODYE
Middle Name:ELLIOTT
Last Name:VISSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELODYE
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-2067
Practice Address - Street 1:1300 BRIDGE BARRIER RD STE 2
Practice Address - Street 2:
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3939
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-2067
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0031921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7985079Medicaid
NC890262Medicaid
NC7985079Medicaid
NC2318323Medicare ID - Type UnspecifiedGROUP#
NC890262Medicaid