Healthcare Provider Details

I. General information

NPI: 1144229451
Provider Name (Legal Business Name): MARIO MELIDONA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

4188 LAKEVILLE RD
GENESEO NY
14454-1134
US

IV. Provider business mailing address

4188 LAKEVILLE RD
GENESEO NY
14454-1134
US

V. Phone/Fax

Practice location:
  • Phone: 585-243-9150
  • Fax: 585-243-4814
Mailing address:
  • Phone: 585-243-9150
  • Fax: 585-243-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number010148
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: