Provider Demographics
NPI:1780761387
Name:MELLOR, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MELLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:REDBANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2579
Practice Address - Country:US
Practice Address - Phone:732-294-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6648401Medicaid
NJG11805Medicare UPIN
NJ6648401Medicaid