Healthcare Provider Details

I. General information

NPI: 1053818815
Provider Name (Legal Business Name): DAVID M MELNICZEK MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S STATE HIGHWAY 49 STE 1&2
JACKSON CA
95642-2685
US

IV. Provider business mailing address

777 S STATE HIGHWAY 49 STE 1&2
JACKSON CA
95642-2685
US

V. Phone/Fax

Practice location:
  • Phone: 209-256-8200
  • Fax: 209-256-8204
Mailing address:
  • Phone: 209-256-8200
  • Fax: 209-256-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA92447
License Number StateCA

VIII. Authorized Official

Name: DAVID MELNICZEK
Title or Position: OWNER
Credential: MD
Phone: 209-256-8200