Provider Demographics
NPI:1720063811
Name:VIDAL MELO, MARCOS F (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:F
Last Name:VIDAL MELO
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST PH 5-505
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-342-4483
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST PH 5-505
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:617-818-5934
Practice Address - Fax:617-726-5985
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158846207L00000X
NY313562-01207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0110451Medicaid
MA158846OtherTUFTS HEALTH PLAN
MAJ23004OtherBCBS MA
H27186Medicare UPIN
MAJ23004OtherBCBS MA