Provider Demographics
NPI:1396737888
Name:ALLEN, MELINDA ROTHER (DO)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ROTHER
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:ANN
Other - Last Name:ROTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-3406
Mailing Address - Country:US
Mailing Address - Phone:580-716-1778
Mailing Address - Fax:918-787-2276
Practice Address - Street 1:100 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-3406
Practice Address - Country:US
Practice Address - Phone:580-716-1778
Practice Address - Fax:918-787-2276
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110245910OtherRR MEDICARE
OK1001360403Medicaid
H30873Medicare UPIN
OK1001360403Medicaid