Healthcare Provider Details

I. General information

NPI: 1366540650
Provider Name (Legal Business Name): MICHAEL GEORGE MELKONIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 RANDOLPH RD
CHARLOTTE NC
28207-1522
US

IV. Provider business mailing address

2104 RANDOLPH ROAD
CHARLOTTE NC
28207-1522
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-3900
  • Fax: 704-377-1244
Mailing address:
  • Phone: 704-377-3900
  • Fax: 704-377-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number300100744
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: