# GM SALLY MELLGREN, M.D. INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1285637637
- **Authorized official:** MS. JOANNE R ROPER (PRACTICE ADMINISTRATOR)
- **Authorized official phone:** (760) 757-1144

## Contact information

- **Practice address:** 3621 VISTA WAY, OCEANSIDE, CA 92056-4522
- **Practice address phone:** (760) 757-1144
- **Practice address fax:** (760) 721-7701
- **Mailing address:** 3621 VISTA WAY, OCEANSIDE, CA 92056-4522
- **Mailing address phone:** (760) 757-1144
- **Mailing address fax:** (760) 721-7701

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207W00000X | Ophthalmology Physician | G53485 | CA | Yes |

## Other

- **Enumeration date:** 05/31/2005
- **Last updated:** 04/25/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00G534850 | — | CA |
| 01 | — | 33-0241763A | HEALTHNET | CA |
| 01 | — | ZZZ07175Z | BLUE SHIELD OF CALIFORNIA | CA |