Provider Demographics
NPI:1700972726
Name:MACBETH, MELANIE C (OD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:C
Last Name:MACBETH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:C
Other - Last Name:MACBETH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:231 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3607
Practice Address - Country:US
Practice Address - Phone:617-484-1414
Practice Address - Fax:617-489-1957
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAA4405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW17558Medicare ID - Type Unspecified
MAV02013Medicare UPIN