Basic Information
| Provider Information | |||||||||
| NPI: | 1578533659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1813 NAGEL RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440116401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409374600 | ||||||||
| FaxNumber: | 4409374605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35-06-6480-M | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 35066480 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5619197341C96 | 01 | OH | BLUECROSS BLUESHIELD | OTHER | 0974594 | 05 | OH | MEDICAID | 3025372 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID |