Provider Demographics
NPI:1750302808
Name:MELLUL EYE & FACIAL PLASTIC SURGERY, P.C.
Entity Type:Organization
Organization Name:MELLUL EYE & FACIAL PLASTIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MELLUL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-334-8227
Mailing Address - Street 1:525 ROUTE 73 S STE 305A
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-9644
Mailing Address - Country:US
Mailing Address - Phone:856-334-8227
Mailing Address - Fax:856-334-8230
Practice Address - Street 1:525 ROUTE 73 S STE 305
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-9642
Practice Address - Country:US
Practice Address - Phone:856-334-8227
Practice Address - Fax:856-334-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07476600207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ089174OtherMEDICARE PTAN
NJ0018198Medicaid
NJ089174OtherMEDICARE PTAN