Healthcare Provider Details

I. General information

NPI: 1235123399
Provider Name (Legal Business Name): YITZHAK A MELAMED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 WESTFORK DR SUITE C
LITHIA SPRINGS GA
30122-1544
US

IV. Provider business mailing address

1515 WESTFORK DR SUITE C
LITHIA SPRINGS GA
30122-1544
US

V. Phone/Fax

Practice location:
  • Phone: 770-941-5552
  • Fax: 770-941-2289
Mailing address:
  • Phone: 770-941-5552
  • Fax: 770-941-2289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38305
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000618659D
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: