Provider Demographics
NPI:1952331407
Name:MELLUL, VICTOR G (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:G
Last Name:MELLUL
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 1:200 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2506
Mailing Address - Country:US
Mailing Address - Phone:856-429-9009
Mailing Address - Fax:856-429-8400
Practice Address - Street 1:200 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2506
Practice Address - Country:US
Practice Address - Phone:856-429-9009
Practice Address - Fax:856-429-8400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04514400207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1664905Medicaid
C56632Medicare UPIN
NJ1664905Medicaid