Provider Demographics
NPI:1740686740
Name:MELDER, GREGORY ALLEN (SA-C)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALLEN
Last Name:MELDER
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3858
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-3858
Mailing Address - Country:US
Mailing Address - Phone:318-636-9905
Mailing Address - Fax:318-636-5102
Practice Address - Street 1:2751 ALBERT L BICKNELL DR STE 3A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3976
Practice Address - Country:US
Practice Address - Phone:318-636-9905
Practice Address - Fax:318-636-5102
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14-576246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant