Provider Demographics
NPI:1285813170
Name:ELIAZO, MELODIA AQUINO (MD)
Entity type:Individual
Prefix:
First Name:MELODIA
Middle Name:AQUINO
Last Name:ELIAZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 R ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1312
Mailing Address - Country:US
Mailing Address - Phone:559-268-9737
Mailing Address - Fax:559-268-0279
Practice Address - Street 1:1045 R ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1312
Practice Address - Country:US
Practice Address - Phone:559-268-9737
Practice Address - Fax:559-268-0279
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A424141Medicaid
CA00A424141Medicaid
CA00A424141Medicare PIN