Provider Demographics
NPI:1922070366
Name:MELLINGER, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 N FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-0957
Mailing Address - Country:US
Mailing Address - Phone:928-774-7757
Mailing Address - Fax:
Practice Address - Street 1:1485 N TURQUOISE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1398
Practice Address - Country:US
Practice Address - Phone:928-774-7757
Practice Address - Fax:928-774-7767
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31185174400000X, 207X00000X, 207XS0106X
AZ33479207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH81771Medicare UPIN
AZ74237Medicare ID - Type Unspecified