Provider Demographics
NPI:1083448625
Name:CHAN, MELISSA VEDETTE (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:VEDETTE
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HUSTON CT
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-4254
Mailing Address - Country:US
Mailing Address - Phone:251-321-2032
Mailing Address - Fax:
Practice Address - Street 1:320 BROADWAY DR SW
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-5348
Practice Address - Country:US
Practice Address - Phone:256-775-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-F42-TA-D39152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty