Provider Demographics
NPI:1982624870
Name:MELLOTT, DEREK (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:MELLOTT
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 1:8277 MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6255
Mailing Address - Country:US
Mailing Address - Phone:330-726-5544
Mailing Address - Fax:330-758-3874
Practice Address - Street 1:8277 MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6246
Practice Address - Country:US
Practice Address - Phone:330-726-5544
Practice Address - Fax:330-758-3874
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2201047OtherUNITED HEALTH CARE
OH0691381Medicaid
OH410035075OtherRAILROAD MEDICARE
OH341605571028OtherCARESOURCE
OH000000226430OtherANTHEM BC/BS
OH2201047OtherUNITED HEALTH CARE
OH0644034Medicare PIN
OH0691381Medicaid