Provider Demographics
NPI:1356781231
Name:MAR, MELODY SUN (MD)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:SUN
Last Name:MAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:
Other - Last Name:SUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1390 KELLY JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3908
Mailing Address - Country:US
Mailing Address - Phone:719-593-1799
Mailing Address - Fax:719-265-3794
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-593-1799
Practice Address - Fax:719-265-3794
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00631072085R0202X
CT62174390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000179179Medicaid
IL125-063128OtherILLINOIS STATE LICENSE