Provider Demographics
NPI:1477391605
Name:MELLO, MISTY (OD)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:MELLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MISTY CLAIRE
Other - Middle Name:PEREZ
Other - Last Name:MELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19327 ACKERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2119
Mailing Address - Country:US
Mailing Address - Phone:858-386-6241
Mailing Address - Fax:
Practice Address - Street 1:12300 SEAL BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2709
Practice Address - Country:US
Practice Address - Phone:562-594-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-20
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist