Provider Demographics
NPI:1427083450
Name:MELLMAN, MICHAEL FRANK (MEDICAL DOCTOR)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FRANK
Last Name:MELLMAN
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 1065
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4475
Mailing Address - Country:US
Mailing Address - Phone:310-643-7494
Mailing Address - Fax:310-643-7498
Practice Address - Street 1:390 N PACIFIC COAST HWY STE 1065
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4483
Practice Address - Country:US
Practice Address - Phone:310-643-7494
Practice Address - Fax:310-643-7498
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92073Medicare UPIN
CAG39340Medicare ID - Type Unspecified