Basic Information
| Provider Information | |||||||||
| NPI: | 1023041902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLOTT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660099 | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910660099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6264476057 | ||||||||
| Practice Location | |||||||||
| Address1: | 27700 MEDICAL CENTER RD | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493641400 | ||||||||
| FaxNumber: | 9493654941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16897 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA16897 | 05 | CA | MEDICAID |