Provider Demographics
NPI:1376582528
Name:MELLEMA, JAMES DALE SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DALE
Last Name:MELLEMA
Suffix:SR
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 1:812 POLLARD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1420
Mailing Address - Country:US
Mailing Address - Phone:408-374-1212
Mailing Address - Fax:408-374-4160
Practice Address - Street 1:812 POLLARD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1420
Practice Address - Country:US
Practice Address - Phone:408-374-1212
Practice Address - Fax:408-374-4160
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAO22280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23000Medicare UPIN
CA20828316Medicare ID - Type Unspecified