Provider Demographics
NPI:1306131602
Name:SHRACK, MELODY A (MD)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:SHRACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:R
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:103 W. PIONEER AVE.
Mailing Address - Street 2:
Mailing Address - City:VIBORG
Mailing Address - State:SD
Mailing Address - Zip Code:57070
Mailing Address - Country:US
Mailing Address - Phone:605-326-5201
Mailing Address - Fax:605-326-5196
Practice Address - Street 1:103 W PIONEER AVE
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070
Practice Address - Country:US
Practice Address - Phone:605-326-5201
Practice Address - Fax:605-326-5196
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0913207Q00000X
IN01071457A207Q00000X
SD12197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201093130Medicaid
IN201093130Medicaid