Provider Demographics
NPI:1801800354
Name:MURRILL, MELVIN MOKISO (MEDICAL DOCTOR)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:MOKISO
Last Name:MURRILL
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4043
Mailing Address - Country:US
Mailing Address - Phone:225-928-0695
Mailing Address - Fax:225-928-3662
Practice Address - Street 1:4560 NORTH BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4043
Practice Address - Country:US
Practice Address - Phone:225-928-0695
Practice Address - Fax:225-928-3662
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0142912080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA720923279OtherTAX IDENTIFICATION NUMBER
LA1305561Medicaid