Basic Information
| Provider Information | |||||||||
| NPI: | 1629062203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELTON | ||||||||
| FirstName: | STEVENS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312874500 | ||||||||
| FaxNumber: | 7312874804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312874500 | ||||||||
| FaxNumber: | 7312874804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD014213 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 14213 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3015669 | 05 | TN | MEDICAID | 0052428 | 01 | BLUE CROSS | OTHER | 8203648 | 01 | CIGNA | OTHER | 7161 | 01 | TLC (MEMPHIS MANAGED CARE | OTHER | 116249 | 01 | BETTER HEALTH PLAN | OTHER | 1240124 | 01 | UNITED HEALTH CARE | OTHER | 4176802 | 01 | TN | BCBS | OTHER | 370008023 | 01 | PALMETTO GBA | OTHER | 4673227 | 01 | AETNA | OTHER |