Basic Information
| Provider Information | |||||||||
| NPI: | 1255627964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 973 MICA DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897057255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 973 MICA DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897057255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 125059818 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 2016-00148 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 17066 | NV | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | A149150 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1255627964 | 05 | NC | MEDICAID | NC2672 | 05 | SC | MEDICAID |