Provider Demographics
NPI:1174586366
Name:MELLINGER, BRETT C (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:C
Last Name:MELLINGER
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 1:532 BROADHOLLOW ROAD
Mailing Address - Street 2:SUITE 142
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4932
Mailing Address - Country:US
Mailing Address - Phone:516-931-0041
Mailing Address - Fax:
Practice Address - Street 1:100 GARDEN CITY PLAZA
Practice Address - Street 2:SUITE 102
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-873-5353
Practice Address - Fax:516-873-8850
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156186208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E40199Medicare UPIN