Provider Demographics
NPI:1902054554
Name:CHARLES MELLA M.D. P.A.
Entity Type:Organization
Organization Name:CHARLES MELLA M.D. P.A.
Other - Org Name:CHARLES MELLA M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-647-2550
Mailing Address - Street 1:315 N LAKEMONT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3205
Mailing Address - Country:US
Mailing Address - Phone:407-647-2550
Mailing Address - Fax:407-647-0616
Practice Address - Street 1:315 N LAKEMONT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-647-2550
Practice Address - Fax:407-647-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28144174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1689663932OtherNPI
D62502Medicare UPIN
FL47383YMedicare PIN