Provider Demographics
NPI:1770570301
Name:MELLON, RICHARD WILSON (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILSON
Last Name:MELLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4404
Mailing Address - Country:US
Mailing Address - Phone:540-985-9862
Mailing Address - Fax:
Practice Address - Street 1:902 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4404
Practice Address - Country:US
Practice Address - Phone:540-985-9862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18831207VX0000X
VA0101242000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics