Provider Demographics
NPI:1912907148
Name:MOORE GOTTSCHALK, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:MOORE GOTTSCHALK
Suffix:
Gender:F
Credentials:
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:300 UNIVERSITY BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182311401Medicaid
TX8970NLOtherBCBS (MDACC)
TX182311402 (MDACC)Medicaid
TX8970NLOtherBCBS (MDACC)
TX8J6241Medicare PIN
TX377790YKQH (MDACC)Medicare PIN