Provider Demographics
NPI:1588850853
Name:MELLON, HERMANN J (MD)
Entity Type:Individual
Prefix:MR
First Name:HERMANN
Middle Name:J
Last Name:MELLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 480389
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33348-0389
Mailing Address - Country:US
Mailing Address - Phone:561-672-7851
Mailing Address - Fax:561-672-7861
Practice Address - Street 1:315 W 9TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3853
Practice Address - Country:US
Practice Address - Phone:786-360-4528
Practice Address - Fax:786-360-4529
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69649208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259474900Medicaid
28965DMedicare PIN
FLG41405Medicare UPIN