Provider Demographics
NPI:1104847268
Name:MELLADO, CARLOS R (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:MELLADO
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:Z15 CALLE YAGRUMO
Mailing Address - Street 2:VALLE ARRIBA HEIGHTS
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-3422
Mailing Address - Country:US
Mailing Address - Phone:787-957-0060
Mailing Address - Fax:
Practice Address - Street 1:Z15 CALLE YAGRUMO
Practice Address - Street 2:VALLE ARRIBA HEIGHTS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-3422
Practice Address - Country:US
Practice Address - Phone:787-957-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
H69230Medicare UPIN
21041Medicare ID - Type Unspecified