MEDICARE: DR. DALE A D'MELLO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	4301039175	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487751723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE A D'MELLO M.D.

Provider Business Mailing Address
First Line	:	A233 E FEE HALL
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48824-1316
Country	:	US
Telephone Number	:	517-353-4363
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 W SAGINAW ST
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48915-1927
Country	:	US
Telephone Number	:	517-364-7700
Fax Number	:	517-364-7701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	12/07/2009

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