Provider Demographics
NPI:1124078829
Name:MELBERG, EDWARD KARL (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:KARL
Last Name:MELBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16757 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-6173
Mailing Address - Country:US
Mailing Address - Phone:715-288-6115
Mailing Address - Fax:
Practice Address - Street 1:2677 S PRAIRIE VIEW RD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-7506
Practice Address - Country:US
Practice Address - Phone:715-726-1671
Practice Address - Fax:715-726-1587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38521300Medicaid
WI38521300Medicaid