Basic Information
| Provider Information | |||||||||
| NPI: | 1104814615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELMAN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1311 NE 1ST ST | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333011711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865562567 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5000 W OAKLAND PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333131503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547356000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | ME40147 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207R00000X | ME40147 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 268739900 | 05 | FL | MEDICAID | 95947V | 01 | FL | MEDICARE PTAN | OTHER | P00436794 | 01 | FL | MEDICATE RAILROAD PTAN | OTHER |