Provider Demographics
NPI:1649253659
Name:MELLERSTIG, KENT E (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:E
Last Name:MELLERSTIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 SLATE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8841
Mailing Address - Country:US
Mailing Address - Phone:707-527-7211
Mailing Address - Fax:707-538-7044
Practice Address - Street 1:1043 SLATE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8841
Practice Address - Country:US
Practice Address - Phone:707-527-7211
Practice Address - Fax:707-538-7044
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG18760208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G187600Medicare ID - Type Unspecified