Provider Demographics
NPI:1366444259
Name:MELLOW, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MELLOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E 60TH ST
Mailing Address - Street 2:#2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1117
Mailing Address - Country:US
Mailing Address - Phone:212-838-4114
Mailing Address - Fax:212-838-4145
Practice Address - Street 1:115 E 57TH ST
Practice Address - Street 2:STE 510
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2221
Practice Address - Country:US
Practice Address - Phone:212-838-4114
Practice Address - Fax:212-838-4145
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146454207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01166449Medicaid
NY25F861Medicare ID - Type Unspecified
NY01166449Medicaid