Healthcare Provider Details

I. General information

NPI: 1093754780
Provider Name (Legal Business Name): SIMON MELNICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 STANLEY ST
FALL RIVER MA
02720-6009
US

IV. Provider business mailing address

386 STANLEY ST
FALL RIVER MA
02720-6009
US

V. Phone/Fax

Practice location:
  • Phone: 508-675-1054
  • Fax: 508-324-7777
Mailing address:
  • Phone: 508-324-3550
  • Fax: 508-676-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO00518
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO00518
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number270103
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: