Provider Demographics
NPI:1932159258
Name:EGGLESTON, MELANIE T (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:T
Last Name:EGGLESTON
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 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8255207R00000X
WAMD00039817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA150433OtherWA LABOR & INDUSTRY
WA8279929Medicaid
ID806070300Medicaid
ID110223939OtherRAILROAD MEDICARE-IDAHO
ID110223939OtherRAILROAD MEDICARE-IDAHO
ID1100918Medicare PIN
ID110223939Medicare ID - Type UnspecifiedRAILROAD MEDICARE