Basic Information
| Provider Information | |||||||||
| NPI: | 1811247885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETCHANDJI | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | NYEH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 S UTICA AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185793130 | ||||||||
| FaxNumber: | 9185793139 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 SOUTH UTICA AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185793130 | ||||||||
| FaxNumber: | 9185793139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 31609 | OK | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200596260A | 05 | OK | MEDICAID |