Provider Demographics
NPI:1720436678
Name:ROOP, MELISSA ARVILLA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ARVILLA
Last Name:ROOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ARVILLA
Other - Last Name:FUELLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:325 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6040
Practice Address - Country:US
Practice Address - Phone:208-514-2525
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13971207Q00000X
IDMRM-1578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1720436678Medicaid