Provider Demographics
NPI:1811153893
Name:MELSTROM, LALEH GOLKAR (MD)
Entity type:Individual
Prefix:DR
First Name:LALEH
Middle Name:GOLKAR
Last Name:MELSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LALEH
Other - Middle Name:
Other - Last Name:GOLKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256669208600000X
IL36114503208600000X
CAC1349792086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0303381Medicaid
NJ260325P3VMedicare PIN