Provider Demographics
NPI:1760786925
Name:MELLENCAMP, DAVID DIXON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DIXON
Last Name:MELLENCAMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9409 PRINCE CHARLES
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3466
Mailing Address - Country:US
Mailing Address - Phone:512-294-2677
Mailing Address - Fax:512-294-2677
Practice Address - Street 1:3970 N OAKLAND AVE
Practice Address - Street 2:300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2265
Practice Address - Country:US
Practice Address - Phone:414-961-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16299-20207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery