Healthcare Provider Details

I. General information

NPI: 1497712079
Provider Name (Legal Business Name): JOHN MELLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE STE 220
FENTON MO
63026-2384
US

IV. Provider business mailing address

1011 BOWLES AVE STE 220
FENTON MO
63026-2384
US

V. Phone/Fax

Practice location:
  • Phone: 636-681-3030
  • Fax: 636-326-1545
Mailing address:
  • Phone: 636-681-3030
  • Fax: 636-326-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR3E73
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: