MEDICARE: DR. GARY J. MELLON OD

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	4901002461	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861472268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY J. MELLON OD

Provider Business Mailing 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	:	231-582-7113

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	:	231-582-7113

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	09/11/2008

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