Provider Demographics
NPI:1750637013
Name:MELLUM, GARY DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DOUGLAS
Last Name:MELLUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 36TH AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5269
Mailing Address - Country:US
Mailing Address - Phone:701-429-7001
Mailing Address - Fax:
Practice Address - Street 1:5621 36TH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5269
Practice Address - Country:US
Practice Address - Phone:701-429-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1039111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor