Basic Information
| Provider Information | |||||||||
| NPI: | 1831288877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELOCOTON | ||||||||
| FirstName: | TERESITA | ||||||||
| MiddleName: | LU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LU | ||||||||
| OtherFirstName: | TERESITA | ||||||||
| OtherMiddleName: | RAZ | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3100 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023884428 | ||||||||
| FaxNumber: | 7023884312 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023884428 | ||||||||
| FaxNumber: | 7023884312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 9127 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 002018826 | 05 | NV | MEDICAID |