Provider Demographics
NPI:1679665624
Name:MELLON, PETER JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:MELLON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13002 PENN SHOP ROAD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-4566
Mailing Address - Country:US
Mailing Address - Phone:301-831-5444
Mailing Address - Fax:301-829-5729
Practice Address - Street 1:13002 PENN SHOP ROAD
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771
Practice Address - Country:US
Practice Address - Phone:301-831-5444
Practice Address - Fax:301-829-5729
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01555111N00000X
MI2301005807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
M505Medicare ID - Type Unspecified
U28513Medicare UPIN