Healthcare Provider Details

I. General information

NPI: 1609871979
Provider Name (Legal Business Name): JAY ROBERT MELLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N SCOTTSDALE RD SUITE 320
SCOTTSDALE AZ
85251-5648
US

IV. Provider business mailing address

3501 N SCOTTSDALE RD SUITE 320
SCOTTSDALE AZ
85251-5648
US

V. Phone/Fax

Practice location:
  • Phone: 480-424-7228
  • Fax: 480-424-7317
Mailing address:
  • Phone: 480-424-7228
  • Fax: 480-424-7317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number15628
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: