Provider Demographics
NPI:1467568998
Name:MELLIN, HAROLD
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:MELLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 NE 20TH TER
Mailing Address - Street 2:SUITE 211
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4510
Mailing Address - Country:US
Mailing Address - Phone:954-491-0500
Mailing Address - Fax:954-491-0633
Practice Address - Street 1:4800 NE 20TH TER
Practice Address - Street 2:SUITE 211
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4510
Practice Address - Country:US
Practice Address - Phone:954-491-0500
Practice Address - Fax:954-491-0633
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262058600Medicaid
FL262058600Medicaid
FL93012Medicare ID - Type Unspecified