Provider Demographics
NPI:1588663108
Name:MELLIS, NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MELLIS
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 1:2352 YORK RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2236
Mailing Address - Country:US
Mailing Address - Phone:410-560-5652
Mailing Address - Fax:410-560-4971
Practice Address - Street 1:2352 YORK RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2236
Practice Address - Country:US
Practice Address - Phone:410-560-5652
Practice Address - Fax:410-560-4971
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD142RMedicare UPIN