Healthcare Provider Details

I. General information

NPI: 1578762969
Provider Name (Legal Business Name): SANDOR MELIAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 W EAU GALLIE BLVD UNIT 104
MELBOURNE FL
32935-4033
US

IV. Provider business mailing address

2010 W EAU GALLIE BLVD UNIT 104
MELBOURNE FL
32935-4033
US

V. Phone/Fax

Practice location:
  • Phone: 321-500-4263
  • Fax: 888-782-9622
Mailing address:
  • Phone: 321-500-4263
  • Fax: 888-782-9622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL # 999
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: