Provider Demographics
NPI:1366423832
Name:MELA, THEOFANIE (MD)
Entity type:Individual
Prefix:DR
First Name:THEOFANIE
Middle Name:
Last Name:MELA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-4662
Mailing Address - Fax:617-726-3852
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:ELECTROPHYSIOLOGY LAB ARRHYTHMIA SERVICE GRB 109
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-4662
Practice Address - Fax:617-726-3852
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA80414207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA779923OtherTUFTS HEALTH PLAN
MAJ21120OtherBCBS MA
MA3193659Medicaid
MAJ21120OtherBCBS MA
MA3193659Medicaid