Provider Demographics
NPI:1588107908
Name:MELVIN, GARY JR
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MELVIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MCDANIEL CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-5002
Mailing Address - Country:US
Mailing Address - Phone:510-435-8492
Mailing Address - Fax:
Practice Address - Street 1:22245 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4028
Practice Address - Country:US
Practice Address - Phone:510-727-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker