Provider Demographics
NPI:1760453856
Name:MELLOH, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MELLOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7649
Mailing Address - Country:US
Mailing Address - Phone:207-795-5709
Mailing Address - Fax:
Practice Address - Street 1:76 HIGH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7649
Practice Address - Country:US
Practice Address - Phone:207-795-5709
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5274Medicare ID - Type Unspecified
MEA17146Medicare UPIN