Basic Information
| Provider Information | |||||||||
| NPI: | 1760419170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELINCOFF | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FROSTWOOD DR | ||||||||
| Address2: | SUITE 1.100 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133385519 | ||||||||
| FaxNumber: | 7137043086 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 WASHINGTON AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770075476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138616490 | ||||||||
| FaxNumber: | 8326585415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 25MB07630200 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QA0505X | P1671 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0038784 | 05 | NJ | MEDICAID |