Healthcare Provider Details

I. General information

NPI: 1164953790
Provider Name (Legal Business Name): ADELINE LEE MELVIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S 5TH AVE
DENTON MD
21629-1398
US

IV. Provider business mailing address

808 S 5TH AVE
DENTON MD
21629-1398
US

V. Phone/Fax

Practice location:
  • Phone: 410-479-2650
  • Fax: 833-908-2283
Mailing address:
  • Phone: 410-479-2650
  • Fax: 339-082-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0089315
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: