Basic Information
| Provider Information | |||||||||
| NPI: | 1144250895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLBLOM | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8320 E MORROW RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863143061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287728633 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | V.A. MEDICAL CENTER NAVAHCS | ||||||||
| Address2: | 500 N HWY 89 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 131T | WY | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.