Provider Demographics
NPI:1174611438
Name:MELICHER, PAUL R (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:MELICHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 4TH ST S STE 612
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1940
Mailing Address - Country:US
Mailing Address - Phone:701-235-0561
Mailing Address - Fax:701-235-0330
Practice Address - Street 1:100 4TH ST S STE 612
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1940
Practice Address - Country:US
Practice Address - Phone:701-235-0561
Practice Address - Fax:701-235-0330
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60346Medicaid
MN2M311MEOtherBLUE SHIELD
ND800428OtherVISION SERVICES
ND11481OtherBLUE SHIELD
NDT66908Medicare UPIN
ND11481Medicare ID - Type Unspecified