Provider Demographics
NPI:1124131073
Name:MELLINGER, DOUGLAS NEAL (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:NEAL
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-656-7020
Mailing Address - Fax:320-255-5943
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2736
Practice Address - Country:US
Practice Address - Phone:320-656-7020
Practice Address - Fax:320-255-5943
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68816208G00000X
CA20A8396208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX83960Medicaid
CAI31970Medicare UPIN
CAW20A8396AMedicare ID - Type Unspecified