Provider Demographics
NPI:1881687465
Name:MELLOR, REED GRANT (MD)
Entity Type:Individual
Prefix:
First Name:REED
Middle Name:GRANT
Last Name:MELLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:REED
Other - Middle Name:GRANT
Other - Last Name:MELLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7373 WEST LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3377
Mailing Address - Country:US
Mailing Address - Phone:209-476-3094
Mailing Address - Fax:
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA971112080A0000X
IA34996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA420681060B8OtherRAILROAD MEDICARE
IAG021OtherTRIWEST
IA02B6930Medicaid
IA34171OtherWELLMARK BCBS OF IOWA
IA220789OtherIOWA HEALTH SOLUTIONS
IA420681060B8OtherRAILROAD MEDICARE
IA220789OtherIOWA HEALTH SOLUTIONS