Healthcare Provider Details

I. General information

NPI: 1518948223
Provider Name (Legal Business Name): JACK PAUL MELMED OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 TWEEDY BLVD
SOUTH GATE CA
90280-4324
US

IV. Provider business mailing address

3329 TWEEDY BLVD
SOUTH GATE CA
90280-4324
US

V. Phone/Fax

Practice location:
  • Phone: 323-566-6183
  • Fax: 323-566-0319
Mailing address:
  • Phone: 323-566-6183
  • Fax: 323-566-0319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: