MEDICARE: MELANIE H LAGOMICHOS DO

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	Q8280	TX

General Provider Information

NPI Number	:	1891053245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE H LAGOMICHOS DO

Provider Business Mailing Address
First Line	:	855 MONTGOMERY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2553
Country	:	US
Telephone Number	:	817-725-7900
Fax Number	:	682-207-1030

Provider Business Practice Location Address
First Line	:	1307 8TH AVE STE 403
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4143
Country	:	US
Telephone Number	:	682-207-1375
Fax Number	:	682-207-1377

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

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	01/09/2020

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