Provider Demographics
NPI:1851354872
Name:MELLICK, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:MELLICK
Suffix:
Gender:F
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:PO BOX 5275
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-5275
Mailing Address - Country:US
Mailing Address - Phone:888-828-3196
Mailing Address - Fax:
Practice Address - Street 1:25 NW 23RD PL
Practice Address - Street 2:SUITE 11
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5580
Practice Address - Country:US
Practice Address - Phone:503-305-6262
Practice Address - Fax:503-305-6078
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17993207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
208975OtherWA L & I
OR057252Medicaid
858543007OtherREGENCE BC/BS
WA8182214Medicaid
WA8182214Medicaid
208975OtherWA L & I
ORR143152Medicare PIN
R132022Medicare PIN