Provider Demographics
NPI:1861472268
Name:MELLON, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:MELLON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1336
Mailing Address - Country:US
Mailing Address - Phone:231-582-6704
Mailing Address - Fax:231-582-7113
Practice Address - Street 1:102 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1336
Practice Address - Country:US
Practice Address - Phone:231-582-6704
Practice Address - Fax:231-582-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI86 1862718Medicaid
MI94 5024936Medicaid
0913350001Medicare NSC
MI0A56501Medicare PIN
MIT32679Medicare UPIN