Healthcare Provider Details

I. General information

NPI: 1144471152
Provider Name (Legal Business Name): MELISSA TABOR D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD SUITE #410
MAYFIELD HTS OH
44124-2203
US

IV. Provider business mailing address

1000 AUBURN DR SUITE #200
BEACHWOOD OH
44122-4317
US

V. Phone/Fax

Practice location:
  • Phone: 440-995-2767
  • Fax: 216-593-0661
Mailing address:
  • Phone:
  • Fax: 216-593-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34.012546
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS 10487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: