Provider Demographics
NPI:1457640062
Name:MELLON, ERIC ALBERT (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ALBERT
Last Name:MELLON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-4200
Mailing Address - Fax:
Practice Address - Street 1:1475 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1178912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program