Basic Information
| Provider Information | |||||||||
| NPI: | 1609850775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELTON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61250 SE COOMBS PL | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417065930 | ||||||||
| FaxNumber: | 5417065931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME90790 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD201470 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7159625 | 01 | FL | AETNA | OTHER | 9227094002 | 01 | FL | CIGNA | OTHER | 48499 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | P00185798 | 01 | FL | RAILROAD MEDICARE | OTHER | 244227 | 01 | FL | WELLCARE | OTHER | 270432300 | 05 | FL | MEDICAID | 3570709 | 01 | FL | AETNA | OTHER |