Provider Demographics
NPI:1770713125
Name:MELLA-PICEL, CARLOS A (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:MELLA-PICEL
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 1:4959 W BELMONT AVE STE N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4332
Mailing Address - Country:US
Mailing Address - Phone:773-930-3649
Mailing Address - Fax:773-930-3974
Practice Address - Street 1:4959 W BELMONT AVE STE N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4332
Practice Address - Country:US
Practice Address - Phone:773-930-3642
Practice Address - Fax:773-930-3974
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.130535207RG0300X
IL125.056702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification