Provider Demographics
NPI:1912102104
Name:ALTIZER, MELANIE DAWN (MD)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:DAWN
Last Name:ALTIZER
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:15901 BASS RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-6100
Practice Address - Fax:239-343-9925
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133006207V00000X
VA0101243301207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022295100Medicaid