Provider Demographics
NPI:1285637637
Name:GM SALLY MELLGREN, M.D. INC.
Entity Type:Organization
Organization Name:GM SALLY MELLGREN, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-757-1144
Mailing Address - Street 1:3621 VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4522
Mailing Address - Country:US
Mailing Address - Phone:760-757-1144
Mailing Address - Fax:760-721-7701
Practice Address - Street 1:3621 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4522
Practice Address - Country:US
Practice Address - Phone:760-757-1144
Practice Address - Fax:760-721-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53485207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G534850Medicaid
CA33-0241763AOtherHEALTHNET
CAZZZ07175ZOtherBLUE SHIELD OF CALIFORNIA
CA33-0241763AOtherHEALTHNET
CA========= 0016OtherCIGNA HEALTHCARE
CS0760Medicare ID - Type UnspecifiedMEDICRE RRR
CA=========OtherBLUE CROSS OF CALIFORNIA
W14638Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER