Provider Demographics
NPI:1720320724
Name:MELQUIST, EZEKIEL DEREK ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:EZEKIEL
Middle Name:DEREK ALEXANDER
Last Name:MELQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 CRESTRIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9706
Mailing Address - Country:US
Mailing Address - Phone:347-677-4264
Mailing Address - Fax:
Practice Address - Street 1:1701 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2077
Practice Address - Country:US
Practice Address - Phone:360-426-2653
Practice Address - Fax:888-985-0681
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61191074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics