Provider Demographics
NPI:1023041902
Name:MELLOTT, JOHN ERIC (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ERIC
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:PA
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 660099
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0099
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:27700 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6426
Practice Address - Country:US
Practice Address - Phone:949-364-1400
Practice Address - Fax:949-365-4941
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16897Medicaid
CAS37858Medicare UPIN
CAWPA16897AMedicare PIN