Basic Information
Provider Information | |||||||||
NPI: | 1609300870 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELAKU | ||||||||
FirstName: | SIMEON | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1430 | ||||||||
Address2: |   | ||||||||
City: | HARRISONBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 228031430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5404773185 | ||||||||
FaxNumber: | 7575798555 | ||||||||
Practice Location | |||||||||
Address1: | 120 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | MOUNT JACKSON | ||||||||
State: | VA | ||||||||
PostalCode: | 228429417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5404773185 | ||||||||
FaxNumber: | 7575798555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2017 | ||||||||
LastUpdateDate: | 09/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | 0102206269 | VA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1609300870 | 05 | VA |   | MEDICAID |