Provider Demographics
NPI:1770772071
Name:MELSON, ENRICO A (MD)
Entity type:Individual
Prefix:DR
First Name:ENRICO
Middle Name:A
Last Name:MELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:17500 FOOTHILL BLVD
Practice Address - Street 2:SUITE A-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3798
Practice Address - Country:US
Practice Address - Phone:909-428-0170
Practice Address - Fax:909-428-5145
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2010-07-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG59473207Q00000X, 2083P0500X, 2083P0901X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720241961OtherMEDI-CAL