Healthcare Provider Details

I. General information

NPI: 1245328764
Provider Name (Legal Business Name): MONICA M MELAMEDOFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 N BROADWAY SUITE L2
JERICHO NY
11753-2109
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 516-931-1776
  • Fax: 516-942-1940
Mailing address:
  • Phone: 516-945-3000
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number162566
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: