Healthcare Provider Details

I. General information

NPI: 1508026832
Provider Name (Legal Business Name): KURT ALLAN MELSTROM JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W CARROLL AVE STE 200
GLENDORA CA
91741-4709
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 626-914-3921
  • Fax: 626-963-0500
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA135013
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036114508
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA135013
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number259161
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: