Provider Demographics
NPI:1699875690
Name:MOOK, MELANIE ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:ANNE
Last Name:MOOK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S HAM LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3533
Mailing Address - Country:US
Mailing Address - Phone:925-309-9812
Mailing Address - Fax:
Practice Address - Street 1:621 S HAM LN
Practice Address - Street 2:SUITE C
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3533
Practice Address - Country:US
Practice Address - Phone:925-309-9812
Practice Address - Fax:209-367-1089
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9509 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA111528Medicare PIN