Basic Information
Provider Information | |||||||||
NPI: | 1083840318 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORVATH | ||||||||
FirstName: | MIA | ||||||||
MiddleName: | MELILLO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MELILLO | ||||||||
OtherFirstName: | MIA | ||||||||
OtherMiddleName: | KATHERINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1620 S STAPLEY DR STE 132 | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852046655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808348804 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1620 S STAPLEY DR STE 132 | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852046655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808348804 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2009 | ||||||||
LastUpdateDate: | 02/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0750 | AZ | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.