Basic Information
| Provider Information | |||||||||
| NPI: | 1225227051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEZ | ||||||||
| FirstName: | LENNY | ||||||||
| MiddleName: | TUA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0784503304 | ||||||||
| FaxNumber: | 8897217528 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 US HIGHWAY 98 S STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636469191 | ||||||||
| FaxNumber: | 8636465252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 16894 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN532 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | FG350A | 01 | FL | MEDICARE | OTHER | 012863800 | 05 | FL | MEDICAID | 1456278 | 01 | WELLCARE | OTHER | P1056619 | 01 | FL | FREEDOM | OTHER | P988170 | 01 | FL | OPTIMUM | OTHER | 1119187 | 01 | FL | CAREPLUS | OTHER | P01756119 | 01 | FL | SIMPLY | OTHER |