Basic Information
| Provider Information | |||||||||
| NPI: | 1336374610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | REPARTO RAMON SOTO 336 | ||||||||
| Address2: | |||||||||
| City: | MANATI | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878845772 | ||||||||
| FaxNumber: | 7876414561 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 CALLE CASIA | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009213200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876417582 | ||||||||
| FaxNumber: | 7876417582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 05/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.