Basic Information
| Provider Information | |||||||||
| NPI: | 1205219995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUILLEN MENDOZA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | KENN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 POPLAR AVE BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012878693 | ||||||||
| FaxNumber: | 9012876804 | ||||||||
| Practice Location | |||||||||
| Address1: | 848 ADAMS AVE STE L400 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012877337 | ||||||||
| FaxNumber: | 9012874540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT209377 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0402X | 61963 | TN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.