Provider Demographics
NPI:1801988316
Name:PROSISE, MELANIE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:MARIE
Last Name:PROSISE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MELANIE
Other - Middle Name:MARIE PROSISE
Other - Last Name:LEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3410 FAR WEST BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3194
Mailing Address - Country:US
Mailing Address - Phone:512-427-1100
Mailing Address - Fax:512-427-1208
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3167
Practice Address - Country:US
Practice Address - Phone:512-427-1100
Practice Address - Fax:512-427-1207
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06143TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157449301Medicaid
TX157449301Medicaid
TX8J2156Medicare PIN