Basic Information
| Provider Information | |||||||||
| NPI: | 1578533667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDICINO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 303 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147885000 | ||||||||
| FaxNumber: | 6147885100 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147885000 | ||||||||
| FaxNumber: | 6147885100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | SC003270L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 567 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | SC003270L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | SC003270L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0103X | 36.003654 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0011607060006 | 05 | PA | MEDICAID | 3026504 | 05 | OH | MEDICAID |