Basic Information
Provider Information | |||||||||
NPI: | 1548478639 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELITZ | ||||||||
FirstName: | CELINE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUCKLEY | ||||||||
OtherFirstName: | CELINE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11995 SINGLETREE LN | ||||||||
Address2: | STE 500 | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553445347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951301 | ||||||||
FaxNumber: | 6122944903 | ||||||||
Practice Location | |||||||||
Address1: | 9943 FIELDTHORN ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921274415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951100 | ||||||||
FaxNumber: | 6122944903 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2007 | ||||||||
LastUpdateDate: | 05/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME 111123 | FL | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD440744 | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | MD-47751 | IA | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | MD-47751 | IA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A 125248 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.