Basic Information
| Provider Information | |||||||||
| NPI: | 1205823796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 GRASSLANDS RD | ||||||||
| Address2: | MUNGER PAVILION STE 120 | ||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144938558 | ||||||||
| FaxNumber: | 9144931488 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144938558 | ||||||||
| FaxNumber: | 9144931488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 148338 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7414706 | 05 | NJ | MEDICAID | 00992998 | 05 | NY | MEDICAID |