Provider Demographics
NPI:1639375884
Name:DEMELLO, DAVID WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:DEMELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:120 PARK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2132
Mailing Address - Country:US
Mailing Address - Phone:920-885-5225
Mailing Address - Fax:920-356-6419
Practice Address - Street 1:36539 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2012
Practice Address - Country:US
Practice Address - Phone:586-900-8225
Practice Address - Fax:920-356-6419
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIDD07358207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4939290Medicaid
MI4939290Medicaid