Provider Demographics
NPI:1932580909
Name:CUSACK, MELINDA MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MICHELLE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:MECHELLE
Other - Last Name:MAILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-478-4201
Mailing Address - Fax:260-458-3293
Practice Address - Street 1:12404 LIMA CROSSING DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-0202
Practice Address - Country:US
Practice Address - Phone:260-478-4201
Practice Address - Fax:260-458-3293
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500878207Q00000X
IN11018213A207Q00000X, 390200000X
MI4301111076390200000X
IN01088779A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program