Provider Demographics
NPI:1043873771
Name:MELVILLE MEDICINE, PLLC
Entity type:Organization
Organization Name:MELVILLE MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MELVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-600-8725
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6464
Mailing Address - Country:US
Mailing Address - Phone:817-676-2010
Mailing Address - Fax:833-989-2353
Practice Address - Street 1:1545 E SOUTHLAKE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6464
Practice Address - Country:US
Practice Address - Phone:817-600-8725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-18
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty