Provider Demographics
NPI:1952362261
Name:MELAMED, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MELAMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1175 WEST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1913
Mailing Address - Country:US
Mailing Address - Phone:516-374-1122
Mailing Address - Fax:516-374-1025
Practice Address - Street 1:1175 WEST BROADWAY
Practice Address - Street 2:SUITE# 25
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1913
Practice Address - Country:US
Practice Address - Phone:516-374-1122
Practice Address - Fax:516-374-1025
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120483207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00325631Medicaid
NYWWQ601Medicare PIN
NYC00062Medicare UPIN
NY00325631Medicaid