Provider Demographics
NPI:1457595456
Name:DECLAIRE, MELODY JOY (MD)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:JOY
Last Name:DECLAIRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 BRIDLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-3362
Mailing Address - Country:US
Mailing Address - Phone:276-632-9714
Mailing Address - Fax:
Practice Address - Street 1:4529 JESSUP GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9407
Practice Address - Country:US
Practice Address - Phone:336-605-0190
Practice Address - Fax:336-605-0930
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201200292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921521Medicaid