Provider Demographics
NPI:1952350654
Name:MELILLO, JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:MELILLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 VALLEY BLVD
Mailing Address - Street 2:108
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2500
Mailing Address - Country:US
Mailing Address - Phone:626-444-2575
Mailing Address - Fax:626-444-2570
Practice Address - Street 1:11100 VALLEY BLVD
Practice Address - Street 2:108
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2500
Practice Address - Country:US
Practice Address - Phone:626-444-2575
Practice Address - Fax:626-444-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4191T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0041910Medicaid
T09596Medicare UPIN
CAOP4191Medicare ID - Type Unspecified