Provider Demographics
NPI:1194988857
Name:BLANTON, MELISSA ANN MISKO (OD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN MISKO
Last Name:BLANTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MISKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1248 CAPSTONE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7293
Mailing Address - Country:US
Mailing Address - Phone:630-881-0780
Mailing Address - Fax:
Practice Address - Street 1:7100 KIT CREEK RD BLDG 9
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-8663
Practice Address - Country:US
Practice Address - Phone:919-392-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2019-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2224152W00000X, 152W00000X
FL4520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01479600Medicaid
NC5922181Medicaid
NCNC9578FMedicare PIN
NCNC9578BMedicare PIN
FL01479600Medicaid
NCNC9578GMedicare PIN
NCNC9578KMedicare PIN
NCNC9578CMedicare PIN
NCNC9578IMedicare PIN
NCNC9578DMedicare PIN
NCNC9578LMedicare PIN
NCNC9578HMedicare PIN
NCNC9578JMedicare PIN
NCNC9578EMedicare PIN
NCNC9578AMedicare PIN