Healthcare Provider Details

I. General information

NPI: 1225172745
Provider Name (Legal Business Name): MICHAEL ALFRED MELLENTHIN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FRESNO & R STREET
FRESNO CA
93721
US

IV. Provider business mailing address

PO BOX 45123
SAN FRANCISCO CA
94145-7733
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG58951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: