Provider Demographics
NPI:1841457439
Name:MELLON, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 N ILLINOIS ST
Practice Address - Street 2:STE 558
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3009
Practice Address - Country:US
Practice Address - Phone:317-688-5500
Practice Address - Fax:317-688-5511
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062033A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000771860OtherANTHEM PIN
IN201066530Medicaid
IN201066530Medicaid
INP01117750Medicare PIN