MEDICARE: DR. MELISSA JEAN GIDLUND O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TA1861	MD

General Provider Information

NPI Number	:	1821167867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA JEAN GIDLUND O.D.

Provider Business Mailing Address
First Line	:	8341 MONTGOMERY RUN RD
Second Line	:	UNIT J
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-7289
Country	:	US
Telephone Number	:	410-740-9952
Fax Number	:	410-740-9731

Provider Business Practice Location Address
First Line	:	10300 LITTLE PATUXENT PKWY
Second Line	:	SUITE 1005B
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3341
Country	:	US
Telephone Number	:	410-740-9952
Fax Number	:	410-740-9731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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