Healthcare Provider Details

I. General information

NPI: 1366022915
Provider Name (Legal Business Name): IAN ALEXANDER MELLIS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

630 WEST 168TH ST PH 1564W
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number327229
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number327229
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number327229
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number327229
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: