MEDICARE: GARY J. MELLON ,O.D.,P.C.

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	152W00000X	Optometrist
2	332H00000X	Eyewear Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7000020361	OTHER	MI	PRIORITY HEALTH

General Provider Information

NPI Number	:	1609045921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY J. MELLON ,O.D.,P.C.

Provider Business Mailing Address
First Line	:	102 E MAIN ST
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-1336
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 E MAIN ST
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-1336
Country	:	US
Telephone Number	:	231-582-6704
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY J. MELLON
Credential	:	O.D.
Telephone Number	:	231-582-6704

Provider Enumeration Date	:	02/21/2008
Last Update Date	:	02/26/2008

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