Healthcare Provider Details

I. General information

NPI: 1649732801
Provider Name (Legal Business Name): MELANIE BOURGEAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-2527
US

IV. Provider business mailing address

PO BOX 100275
GAINESVILLE FL
32610-0275
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7839
  • Fax: 352-273-8172
Mailing address:
  • Phone: 352-273-7839
  • Fax: 352-273-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberDR.0069965
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME168627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: