Provider Demographics
NPI:1659390532
Name:MELLOR, RICHARD J (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:J
Last Name:MELLOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 BEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310
Mailing Address - Country:US
Mailing Address - Phone:718-415-9057
Mailing Address - Fax:718-727-3229
Practice Address - Street 1:36 PLAZA ST E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5039
Practice Address - Country:US
Practice Address - Phone:718-636-1414
Practice Address - Fax:888-583-1255
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ08P31Medicare Oscar/Certification
NYQ08P31Medicare PIN