Healthcare Provider Details

I. General information

NPI: 1548478639
Provider Name (Legal Business Name): CELINE MELITZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CELINE BUCKLEY MD

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9943 FIELDTHORN ST
SAN DIEGO CA
92127-4415
US

IV. Provider business mailing address

11995 SINGLETREE LN STE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD-47751
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME 111123
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD440744
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD-47751
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA 125248
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: