Provider Demographics
NPI:1275562456
Name:MELLOS, ADRIANNE H (MD)
Entity Type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:H
Last Name:MELLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADRIANNE
Other - Middle Name:H
Other - Last Name:MELLOS-POLENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:44-01 FRANCIS LEWIS BOULEVARD
Mailing Address - Street 2:SUITE L3A
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3002
Mailing Address - Country:US
Mailing Address - Phone:718-423-3355
Mailing Address - Fax:718-423-3721
Practice Address - Street 1:44-01 FRANCIS LEWIS BOULEVARD
Practice Address - Street 2:SUITE L3A
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3002
Practice Address - Country:US
Practice Address - Phone:718-423-3355
Practice Address - Fax:718-423-3721
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222001207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02578045Medicaid
NYI13703Medicare UPIN
G400094864Medicare PIN
A400091994Medicare PIN