Healthcare Provider Details

I. General information

NPI: 1144140831
Provider Name (Legal Business Name): MELISSA RENE KORDUCAVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 INTREPID LN
SYRACUSE NY
13205-2548
US

IV. Provider business mailing address

185 POPLAR HILL RD
BINGHAMTON NY
13901-6031
US

V. Phone/Fax

Practice location:
  • Phone: 315-724-4286
  • Fax: 315-724-4170
Mailing address:
  • Phone: 607-621-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number44226
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: