1982624870 NPI number — DR. DEREK MELLOTT O.D.

Table of content: DR. DEREK MELLOTT O.D. (NPI 1982624870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982624870 NPI number — DR. DEREK MELLOTT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLOTT
Provider First Name:
DEREK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982624870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8277 MARKET ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BOARDMAN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-6255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-726-5544
Provider Business Mailing Address Fax Number:
330-758-3874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8277 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-6246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-726-5544
Provider Business Practice Location Address Fax Number:
330-758-3874
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3951 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2201047 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0691381 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410035075 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341605571028 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000226430 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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