Healthcare Provider Details

I. General information

NPI: 1679764179
Provider Name (Legal Business Name): MELISSA KAGNOFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD SUITE 2301
SAN DIEGO CA
92120-5244
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 619-582-2595
  • Fax: 619-229-8006
Mailing address:
  • Phone: 928-759-5874
  • Fax: 928-458-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA121332
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number27100
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA121332
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number58383
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number66706
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: