Basic Information
| Provider Information | |||||||||
| NPI: | 1922070366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELLINGER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2208 N FREMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860010957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1485 N TURQUOISE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860011398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747757 | ||||||||
| FaxNumber: | 9287747767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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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 | 207X00000X | 33479 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 31185 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 33479 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 31185 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 174400000X | 31185 | AZ | N | Other Service Providers | Specialist |
No ID Information.