Basic Information
| Provider Information | |||||||||
| NPI: | 1306295084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOCEVAR | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
| FaxNumber: | 2604585636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 STULTS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467501291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557667762 | ||||||||
| FaxNumber: | 2605692494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 07001308A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 41000343A | 01 | IN | IN MEDICAL LICENSE | OTHER |