Provider Demographics
NPI:1194802546
Name:MELAMED, MICHAEL L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:MELAMED
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 1:11 JODI CT
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1470
Mailing Address - Country:US
Mailing Address - Phone:516-759-0781
Mailing Address - Fax:516-759-0750
Practice Address - Street 1:11 JODI CT
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1470
Practice Address - Country:US
Practice Address - Phone:516-759-0781
Practice Address - Fax:516-759-0750
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00739551Medicaid
NYB79077Medicare UPIN