Provider Demographics
NPI:1366551053
Name:FORAKER, MELISSA MACHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MACHELLE
Last Name:FORAKER
Suffix:
Gender:F
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:PO BOX 121
Mailing Address - Street 2:436 1ST STREET
Mailing Address - City:BETHESDA
Mailing Address - State:OH
Mailing Address - Zip Code:43719-0121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 MAYSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-8577
Practice Address - Country:US
Practice Address - Phone:740-452-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FO4064452Medicare PIN