Provider Demographics
NPI:1457356602
Name:MELLIN, DAVID THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THOMAS
Last Name:MELLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:MELLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3921
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3200
Practice Address - Fax:574-296-3921
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029375A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112340AMedicaid
INC24664Medicare UPIN
IN227950RRRMedicare PIN