Provider Demographics
NPI:1205462090
Name:MELLINGER, JOHN LE ROY (ABOC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LE ROY
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2813
Mailing Address - Country:US
Mailing Address - Phone:626-303-2030
Mailing Address - Fax:626-303-2190
Practice Address - Street 1:509 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2813
Practice Address - Country:US
Practice Address - Phone:626-303-2030
Practice Address - Fax:626-303-2190
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000272156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician