Basic Information
| Provider Information | |||||||||
| NPI: | 1073839759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENDOZA MEDICAL CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROBERTO C MENDOZA,M.D.APMC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 WILLIAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700654505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044431744 | ||||||||
| FaxNumber: | 5044431752 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 WILLIAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044431744 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 09/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | MENDOZA | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
| AuthorizedOfficialMiddleName: | CLEMENTE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5044431744 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2118099 | 05 | LA | MEDICAID | 1191272 | 05 | LA | MEDICAID |