Healthcare Provider Details

I. General information

NPI: 1548333982
Provider Name (Legal Business Name): GREGORY WAYNE MELLOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 W PUTNAM AVE #2B
PORTERVILLE CA
93257-3257
US

IV. Provider business mailing address

590 W PUTNAM AVE #2B
PORTERVILLE CA
93257-3257
US

V. Phone/Fax

Practice location:
  • Phone: 559-782-1973
  • Fax: 559-782-1976
Mailing address:
  • Phone: 559-782-1973
  • Fax: 559-782-1976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG40981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: