Provider Demographics
NPI:1982893665
Name:ILLICH, MELANIE B (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:B
Last Name:ILLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5010 LAKELAND CIRCLE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2981
Mailing Address - Country:US
Mailing Address - Phone:254-776-3486
Mailing Address - Fax:254-776-8466
Practice Address - Street 1:5010 LAKELAND CIRCLE
Practice Address - Street 2:SUITE B
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2981
Practice Address - Country:US
Practice Address - Phone:254-776-3486
Practice Address - Fax:254-776-8466
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ21042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG08042OtherUPIN
TX113408204Medicaid
TX00291GOtherBCBS
TX274459OtherSCOTT & WHITE HEALTH