Healthcare Provider Details

I. General information

NPI: 1871856492
Provider Name (Legal Business Name): ROSS RICHARD MELVIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W BALDWIN RD STE C
PANAMA CITY FL
32405-3359
US

IV. Provider business mailing address

625 W BALDWIN RD STE C
PANAMA CITY FL
32405-3359
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-0329
  • Fax: 844-563-8135
Mailing address:
  • Phone: 850-769-0329
  • Fax: 844-212-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101020121
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberOS19614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: