Provider Demographics
NPI:1699713594
Name:FUSSELL, MELVIN LEE CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:LEE CHRISTOPHER
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3632
Mailing Address - Country:US
Mailing Address - Phone:478-333-6961
Mailing Address - Fax:478-333-6964
Practice Address - Street 1:1770 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3632
Practice Address - Country:US
Practice Address - Phone:478-333-6961
Practice Address - Fax:478-333-6964
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052565208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA162941944HMedicaid
GA162941944GMedicaid
GA162941944FMedicaid
GA34BDDLBMedicare PIN
GAH82389Medicare UPIN