Provider Demographics
NPI:1104027697
Name:MELKUN, FERNANDO (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:MELKUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1010
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:177-576-5372
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1010
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:177-576-5372
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017903207L00000X
IL036146948207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101740083Medicaid
MN1104027697Medicaid
KY7100200820Medicaid
IL$$$$$$$$$Medicare PIN
MO101740083Medicare PIN