Basic Information
| Provider Information | |||||||||
| NPI: | 1740368992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MELISSA ESHELMAN, MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 NE GLISAN ST | ||||||||
| Address2: | 3E | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032157462 | ||||||||
| FaxNumber: | 5032157460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | ESHELMAN | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5032157462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD18604 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 149999 | 05 | OR | MEDICAID |