Provider Demographics
NPI:1912789710
Name:MELONE, ETHAN JAMES (SOIDC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JAMES
Last Name:MELONE
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10025 MARSHALL POND RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3735
Mailing Address - Country:US
Mailing Address - Phone:703-597-3817
Mailing Address - Fax:
Practice Address - Street 1:UNIT 36180 3D RECONNAISSANCE BATTALION, H&S, BAS
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96389-6180
Practice Address - Country:US
Practice Address - Phone:703-597-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02236644EM1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman