Provider Demographics
NPI:1154385169
Name:TADA, MELISSA ANNE (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANNE
Last Name:TADA
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 ANASAZI CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3487
Mailing Address - Country:US
Mailing Address - Phone:719-380-6808
Mailing Address - Fax:719-380-5656
Practice Address - Street 1:6071 E WOODMEN RD
Practice Address - Street 2:SUITE 205
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2607
Practice Address - Country:US
Practice Address - Phone:719-380-6808
Practice Address - Fax:719-380-5656
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO809893OtherMEDICARE PTAN
CO01330357Medicaid
COU77458Medicare UPIN
CO6228970001Medicare NSC
CO01330357Medicaid