Basic Information
| Provider Information | |||||||||
| NPI: | 1336568146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052713013 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052711926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2014 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 31296 | OK | N | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207WX0109X | 31296 | OK | Y |
ID Information
| ID | Type | State | Issuer | Description | 200594690A | 05 | OK | MEDICAID |