Provider Demographics
NPI:1396724886
Name:MELLISH, DAVID J (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:MELLISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-0826
Mailing Address - Country:US
Mailing Address - Phone:856-728-1111
Mailing Address - Fax:
Practice Address - Street 1:490 N BLACK HORSE PIKE
Practice Address - Street 2:SUITE A
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-1404
Practice Address - Country:US
Practice Address - Phone:856-728-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00409300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ172453OtherHORIZON BCBS
NJ1792300Medicaid
NJ222472032OtherATLANTICARE
NJ1066177OtherAETNA
NJ0973042-005OtherCIGNA
NJ172453Medicare PIN
NJ1066177OtherAETNA