Provider Demographics
NPI:1255352209
Name:DAVID A MELLUL DPM
Entity type:Organization
Organization Name:DAVID A MELLUL DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELLUL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-429-9009
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD1488213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ209900401Medicaid
NJ209900401Medicaid
NJ4315010001Medicare NSC
NJ024716Medicare PIN