Provider Demographics
NPI:1780614495
Name:KOUBA, MELISSA MILLER (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MILLER
Last Name:KOUBA
Suffix:
Gender:F
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:ONE HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-884-9066
Practice Address - Fax:573-884-3037
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001009493207R00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147494OtherBLUESHIELD/BLUE CHOICE
MO464041OtherHEALTHLINK
MO205363906Medicaid
MO405522OtherUNITED HEALTHCARE
MOP00147529Medicare PIN
MO923475236Medicare PIN
MO464041OtherHEALTHLINK
MO205363906Medicaid
MOP00433375Medicare PIN