Basic Information
| Provider Information | |||||||||
| NPI: | 1669438651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 TUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539133319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083553800 | ||||||||
| FaxNumber: | 6083557001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 TUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539133319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083553800 | ||||||||
| FaxNumber: | 6083557001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 37504-020 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1000254 | 01 | WI | PHYSICIANS PLUS | OTHER | 5619 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 32205200 | 05 | WI | MEDICAID |