Healthcare Provider Details

I. General information

NPI: 1629185897
Provider Name (Legal Business Name): JUAN F MELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 S SAM HOUSTON BLVD
HOUSTON MO
65483-2046
US

IV. Provider business mailing address

1337 S SAM HOUSTON BLVD
HOUSTON MO
65483-2046
US

V. Phone/Fax

Practice location:
  • Phone: 417-967-5435
  • Fax: 417-967-5503
Mailing address:
  • Phone: 417-967-5435
  • Fax: 417-967-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35.097185
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301042635
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2014020901
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: