Provider Demographics
NPI:1366426298
Name:MELLOW, MARK HARRIS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HARRIS
Last Name:MELLOW
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Gender:M
Credentials:MD
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-713-4430
Mailing Address - Fax:405-713-4429
Practice Address - Street 1:3366 NW EXPRESSWAY ST
Practice Address - Street 2:650
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4462
Practice Address - Country:US
Practice Address - Phone:405-713-4430
Practice Address - Fax:405-713-4429
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-04-02
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Provider Licenses
StateLicense IDTaxonomies
OK14105207RG0100X
MA36011207RG0100X
NY108354207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100019460AMedicaid
OK100019460AMedicaid