Provider Demographics
NPI:1629185897
Name:MELLA, JUAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:F
Last Name:MELLA
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 1:1337 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-5435
Mailing Address - Fax:417-967-5503
Practice Address - Street 1:1337 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-5435
Practice Address - Fax:417-967-5503
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.097185207RP1001X
MI4301042635207RP1001X
MO2014020901207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000722678OtherANTHEM
WV3810020716Medicaid
MO26D0889777OtherCLIA
OH0050111Medicaid
OH000000720256OtherANTHEM
MI1629185897Medicaid
MO1629185897Medicaid
AR204079001Medicaid
MO991084088OtherMEDICARE PTAN #
OH0050111Medicaid
OHH003820Medicare PIN
MO26D0889777OtherCLIA
MO121690020Medicare PIN
WV3810020716Medicaid