Provider Demographics
NPI:1043367238
Name:MELAD, JEROME DIZON
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:DIZON
Last Name:MELAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25401 CABOT RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5513
Mailing Address - Country:US
Mailing Address - Phone:949-588-7011
Mailing Address - Fax:949-588-7012
Practice Address - Street 1:25401 CABOT RD STE 112
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5513
Practice Address - Country:US
Practice Address - Phone:949-588-7011
Practice Address - Fax:949-588-7012
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28517111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28517Medicare UPIN
CACQ379ZMedicare PIN