Healthcare Provider Details

I. General information

NPI: 1134299407
Provider Name (Legal Business Name): EDWARD GERARD MELTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 S GARNETT RD
TULSA OK
74128-1803
US

IV. Provider business mailing address

PO BOX 35264
TULSA OK
74153-0264
US

V. Phone/Fax

Practice location:
  • Phone: 918-361-1501
  • Fax: 918-764-9275
Mailing address:
  • Phone: 918-764-9300
  • Fax: 918-764-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24098
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number24098
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: