Basic Information
| Provider Information | |||||||||
| NPI: | 1114216363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEZ | ||||||||
| FirstName: | BERNARDINO | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1124 ESSINGTON RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604358423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306511115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1124 ESSINGTON RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604358423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153731004 | ||||||||
| FaxNumber: | 8157443969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2011 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 01084266A | IN | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | 1114216363 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | M53207384272 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208200000X | 036148384 | IL | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.