Provider Demographics
NPI:1053355669
Name:WALLINGA, MELVIN (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:WALLINGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BON HOMME FAMILY PRACTICE
Mailing Address - Street 2:410 W 16TH AVE
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-2318
Mailing Address - Country:US
Mailing Address - Phone:605-589-2190
Mailing Address - Fax:605-589-2115
Practice Address - Street 1:410 WEST 16TH AVE
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066-0027
Practice Address - Country:US
Practice Address - Phone:605-589-3341
Practice Address - Fax:605-589-3288
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD5033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5601810Medicaid
SD9205043OtherDAKOTACARE
SD4996770OtherBCBS
SD4996770OtherBCBS
SDA03729Medicare UPIN