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General NPI Number Information
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NPI Number | 1184709339
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Entity Type | Individual
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Provider Name | GRACE M SALLY MELLGREN M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 04/10/2024
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Provider Practice Location Address
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Address Line | 342 SHERRILL LN
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City | ROSWELL
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State | NM
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Zip | 88201-5819
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Country | US
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Telephone | 575-625-0123
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Fax | 575-625-0131
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Provider Business Mailing Address
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Address Line | 342 SHERRILL LN
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City | ROSWELL
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State | NM
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Zip | 88201-5819
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Country | US
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Telephone | 575-625-0123
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Fax | 760-721-7701
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | MD2015-0927
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | G53485
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License Number State | CA
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