Provider Demographics
NPI:1710135785
Name:MELLENDER, SCOTT JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JASON
Last Name:MELLENDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LIBERTY WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08880-1494
Mailing Address - Country:US
Mailing Address - Phone:914-420-5680
Mailing Address - Fax:
Practice Address - Street 1:125 PATERSON ST # 3100
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07582100207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00953299OtherRR MCR PTAN
NJ0236268Medicaid
NJ0236268Medicaid
NJ187642DBHMedicare PIN
NJ187642CDYMedicare PIN
NJ187642CDZMedicare PIN