Provider Demographics
NPI:1457716813
Name:MELLOY, BRIAN DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DANIEL
Last Name:MELLOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 20TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1100
Mailing Address - Country:US
Mailing Address - Phone:479-278-7010
Mailing Address - Fax:479-974-2009
Practice Address - Street 1:200 S 20TH ST STE C
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1100
Practice Address - Country:US
Practice Address - Phone:479-278-7010
Practice Address - Fax:479-974-2009
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
ARE-11091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program