Provider Demographics
NPI:1669589081
Name:VARDEMAN, MELANIE MONTES (OD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:MONTES
Last Name:VARDEMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632767
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-2767
Mailing Address - Country:US
Mailing Address - Phone:936-564-2634
Mailing Address - Fax:936-564-0387
Practice Address - Street 1:4729 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1607
Practice Address - Country:US
Practice Address - Phone:936-564-2634
Practice Address - Fax:936-564-0387
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5757TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX038446302Medicaid
TX5757TGOtherSTATE LICENSE
TX038446302Medicaid
TX5757TGOtherSTATE LICENSE