Basic Information
| Provider Information | |||||||||
| NPI: | 1932161403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELTON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | JASPER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8594283923 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VIOLET RD | ||||||||
| Address2: | |||||||||
| City: | CRITTENDEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410307480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594281610 | ||||||||
| FaxNumber: | 8594283923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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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 | 207Q00000X | 20207 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64202070 | 05 | KY | MEDICAID | 2151193 | 05 | OH | MEDICAID |