Provider Demographics
NPI:1396092961
Name:ENEVOLDSEN, MELISSA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:ENEVOLDSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6708 RAYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-5272
Mailing Address - Country:US
Mailing Address - Phone:816-353-1872
Mailing Address - Fax:
Practice Address - Street 1:6708 RAYTOWN RD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5272
Practice Address - Country:US
Practice Address - Phone:816-353-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1926152W00000X
MO2012017234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA1383003Medicare PIN