Provider Demographics
NPI:1437181146
Name:MELLEN, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MELLEN
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 1:1801 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1227
Mailing Address - Country:US
Mailing Address - Phone:248-626-0766
Mailing Address - Fax:248-626-7498
Practice Address - Street 1:30400 TELEGRAPH RD
Practice Address - Street 2:SUITE 357
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4537
Practice Address - Country:US
Practice Address - Phone:248-646-9806
Practice Address - Fax:248-646-9828
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM029356174400000X
MI43010293562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46140Medicare UPIN