Provider Demographics
NPI:1053597955
Name:MCMELLEN, MARK EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:MCMELLEN
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 1:11600 W SECOND PL
Mailing Address - Street 2:TRAUMA DEPT.
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228
Mailing Address - Country:US
Mailing Address - Phone:314-251-6440
Mailing Address - Fax:314-251-4456
Practice Address - Street 1:11600 W SECOND PL
Practice Address - Street 2:TRAUMA DEPT.
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228
Practice Address - Country:US
Practice Address - Phone:314-251-6440
Practice Address - Fax:314-251-4456
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090124592086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053597955Medicaid