Provider Demographics
NPI:1104064864
Name:GAITANIS, MELINDA LEE (MA55295)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:LEE
Last Name:GAITANIS
Suffix:
Gender:F
Credentials:MA55295
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:491 N HATHAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONSON
Mailing Address - State:FL
Mailing Address - Zip Code:32621-6122
Mailing Address - Country:US
Mailing Address - Phone:352-281-9651
Mailing Address - Fax:352-486-2974
Practice Address - Street 1:490 E HATHAWAY AVE
Practice Address - Street 2:
Practice Address - City:BRONSON
Practice Address - State:FL
Practice Address - Zip Code:32621-6736
Practice Address - Country:US
Practice Address - Phone:352-486-6899
Practice Address - Fax:352-486-2974
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA55295174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist