Provider Demographics
NPI:1053532044
Name:DE MELLO, EDISON VICTOR (MD PHD)
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:VICTOR
Last Name:DE MELLO
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 ARIZONA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401
Mailing Address - Country:US
Mailing Address - Phone:310-451-8880
Mailing Address - Fax:310-451-8803
Practice Address - Street 1:520 ARIZONA AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401
Practice Address - Country:US
Practice Address - Phone:310-451-8880
Practice Address - Fax:310-451-8803
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN78519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine