Provider Demographics
NPI:1881905362
Name:YELANICH, MELISSA R (MD)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:R
Last Name:YELANICH
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 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-906-4623
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:823 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4541
Practice Address - Country:US
Practice Address - Phone:619-906-4623
Practice Address - Fax:619-906-4564
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA122649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA122649OtherLIC