Provider Demographics
NPI:1639490576
Name:MELLOTT, JUSTIN L (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:480-580-4452
Mailing Address - Fax:
Practice Address - Street 1:2075 UNIVERSITY PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1611
Practice Address - Country:US
Practice Address - Phone:801-786-7500
Practice Address - Fax:801-737-9531
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9428298-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine