Healthcare Provider Details

I. General information

NPI: 1972572766
Provider Name (Legal Business Name): SCOTT R MELLING O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HANAU HEALTH CLINIC ATTN: OPTOMETRY UNIT 20193 BOX 0030
APO AE
09165
DE

IV. Provider business mailing address

CMR 470 BOX 4871
APO AE
09165
DE

V. Phone/Fax

Practice location:
  • Phone: 061815006605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD-988
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: