Provider Demographics
NPI:1598043135
Name:MELLO, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MELLO
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 1:701 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 TRAFALGAR CT
Practice Address - Street 2:SUITE 200E
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4132
Practice Address - Country:US
Practice Address - Phone:407-667-0444
Practice Address - Fax:407-667-4338
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126939207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherBCBS
FLPENDINGMedicaid
FLPENDINGMedicaid