Healthcare Provider Details

I. General information

NPI: 1922070366
Provider Name (Legal Business Name): MARK D MELLINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 N JASPER DR STE 2
FLAGSTAFF AZ
86001-1634
US

IV. Provider business mailing address

2208 N FREMONT BLVD
FLAGSTAFF AZ
86001-0957
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 928-774-7757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number31185
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number33479
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number33479
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31185
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number31185
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: