Provider Demographics
NPI:1164635009
Name:MEHALL, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:MEHALL
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 1:2222 N. NEVADA AVENUE
Mailing Address - Street 2:SUITE 5011
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907
Mailing Address - Country:US
Mailing Address - Phone:719-776-7600
Mailing Address - Fax:719-473-3553
Practice Address - Street 1:2222 N. NEVADA AVENUE
Practice Address - Street 2:SUITE 5011
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-776-7600
Practice Address - Fax:719-473-3553
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45535208G00000X
TXK7453208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19150873Medicaid
G96587Medicare UPIN
COC809810Medicare PIN
CO19150873Medicaid