Healthcare Provider Details

I. General information

NPI: 1922058429
Provider Name (Legal Business Name): DEREK JOSEPH MELTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4061 HWY PP SUITE 1 MELTON EYE CARE ASSOCIATES
POPLAR BLUFF MO
63901
US

IV. Provider business mailing address

99 SKYVIEW ROAD (FORMER DAEOC HEADSTART BLDG) MELTON EYE CARE ASSOCIATES/PORTAGEVILLE EYE CLINIC
PORTAGEVILLE MO
63873
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-9143
  • Fax: 573-778-9164
Mailing address:
  • Phone: 573-714-4324
  • Fax: 573-778-9143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2004006937
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number128991
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMO2004006937
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier317617207
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: