Provider Demographics
NPI:1922058429
Name:MELTON, DEREK JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JOSEPH
Last Name:MELTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:99 SKYVIEW ROAD (FORMER DAEOC HEADSTART BLDG)
Mailing Address - Street 2:MELTON EYE CARE ASSOCIATES/PORTAGEVILLE EYE CLINIC
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873
Mailing Address - Country:US
Mailing Address - Phone:573-714-4324
Mailing Address - Fax:573-778-9143
Practice Address - Street 1:4061 HWY PP SUITE 1
Practice Address - Street 2:MELTON EYE CARE ASSOCIATES
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-778-9143
Practice Address - Fax:573-778-9164
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004006937152WC0802X
IA128991152WC0802X
MOMO2004006937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317617207Medicaid
MO000025912Medicare PIN
000025912Medicare PIN
MO5709250001Medicare NSC
U81338Medicare UPIN
MOU81338Medicare UPIN