Provider Demographics
NPI:1497712079
Name:MELLAS, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MELLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1011 BOWLES AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2384
Mailing Address - Country:US
Mailing Address - Phone:636-681-3030
Mailing Address - Fax:636-326-1545
Practice Address - Street 1:1011 BOWLES AVE STE 220
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2384
Practice Address - Country:US
Practice Address - Phone:636-681-3030
Practice Address - Fax:636-326-1545
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR3E73207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202250106Medicaid
A10327Medicare UPIN
MO202250106Medicaid