Provider Demographics
NPI:1932161403
Name:MELTON, GARY JASPER (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JASPER
Last Name:MELTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1673
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-428-3923
Practice Address - Street 1:520 VIOLET RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-7480
Practice Address - Country:US
Practice Address - Phone:859-428-1610
Practice Address - Fax:859-428-3923
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2015-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY20207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64202070Medicaid
OH2151193Medicaid
KY080170515Medicare PIN
KY64202070Medicaid
KY0364940Medicare PIN