Healthcare Provider Details

I. General information

NPI: 1518175579
Provider Name (Legal Business Name): MELISSA M. M. AGOUDEMOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD SUITE 2204
MERIDIAN ID
83642-6351
US

IV. Provider business mailing address

520 S EAGLE RD SUITE 2204
MERIDIAN ID
83642-6351
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-9188
  • Fax: 208-336-2636
Mailing address:
  • Phone: 208-336-9188
  • Fax: 208-336-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR-8001
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number036-125447
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: