Healthcare Provider Details

I. General information

NPI: 1104767854
Provider Name (Legal Business Name): MELISSA ELDRED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3222 W BROADWAY ST
ARDMORE OK
73401-9645
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 714-231-5369
  • Fax:
Mailing address:
  • Phone: 580-319-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: