Provider Demographics
NPI:1184709339
Name:MELLGREN, GRACE M SALLY (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M SALLY
Last Name:MELLGREN
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 1:342 SHERRILL LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5819
Mailing Address - Country:US
Mailing Address - Phone:575-625-0123
Mailing Address - Fax:760-721-7701
Practice Address - Street 1:342 SHERRILL LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5819
Practice Address - Country:US
Practice Address - Phone:575-625-0123
Practice Address - Fax:575-625-0131
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0927207W00000X
CAG53485207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07175ZOtherBLUE SHIELD OF CA
CA00G53480Medicaid
CAZZZ07175ZOtherBLUE SHIELD OF CA
A93231Medicare UPIN
WG53485AMedicare ID - Type UnspecifiedMEDICARE PROVIDER