Healthcare Provider Details

I. General information

NPI: 1154522944
Provider Name (Legal Business Name): MELISSA MCCARTY STATHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLD MILTON PKWY STE C465
ALPHARETTA GA
30005-4429
US

IV. Provider business mailing address

3400-C OLD MILTON PARKWAY SUITE 465
ALPHARETTA GA
30005
US

V. Phone/Fax

Practice location:
  • Phone: 770-777-1100
  • Fax: 770-751-9089
Mailing address:
  • Phone: 770-777-1100
  • Fax: 770-751-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number64077
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number64077
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: