Provider Demographics
NPI:1992932149
Name:MCCORMACK, MELISSA MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:28319 HAWKS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-5022
Mailing Address - Country:US
Mailing Address - Phone:517-927-4138
Mailing Address - Fax:
Practice Address - Street 1:301 SETON PKWY STE 407
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8003
Practice Address - Country:US
Practice Address - Phone:512-324-4071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019090207V00000X
CA20A15522207V00000X
390200000X
TXS3241207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty