=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629185897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN F MELLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1337 S SAM HOUSTON BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65483-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-967-5435
-----------------------------------------------------
Fax | 417-967-5503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1337 S SAM HOUSTON BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65483-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-967-5435
-----------------------------------------------------
Fax | 417-967-5503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 35.097185
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 4301042635
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 2014020901
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------