Provider Demographics
NPI:1578705067
Name:DATTALO, MELISSA NICOLE (MD, MPH)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
Last Name:DATTALO
Suffix:
Gender:
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N MAIN ST STE 219
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:630-682-3727
Practice Address - Street 1:1800 N MAIN ST STE 219
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-614-4960
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60700-20207RG0300X
IL036173580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055690400Medicaid
MD242107Y82Medicare PIN