Provider Demographics
NPI:1699203125
Name:MELLA, CHARLI ATHENA (MD)
Entity Type:Individual
Prefix:
First Name:CHARLI
Middle Name:ATHENA
Last Name:MELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:NORTHEAST TARRANT INTERNAL MEDICINE ASSOCIATES, LLP
Mailing Address - Street 2:479 WESTPARK WAY
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040
Mailing Address - Country:US
Mailing Address - Phone:817-358-5500
Mailing Address - Fax:817-358-5511
Practice Address - Street 1:479 WESTPARK WAY
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3957
Practice Address - Country:US
Practice Address - Phone:817-358-5500
Practice Address - Fax:817-358-5511
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73958-20208M00000X
390200000X
IL125070689207R00000X
TXS9939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102997Medicaid