Provider Demographics
NPI:1447319405
Name:MELLINGER, CHARLES LEE (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEE
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 HALF MILE LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890
Mailing Address - Country:US
Mailing Address - Phone:203-255-6471
Mailing Address - Fax:
Practice Address - Street 1:2600 POST RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890
Practice Address - Country:US
Practice Address - Phone:203-255-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410000281Medicare ID - Type Unspecified
T20212Medicare UPIN