Basic Information
| Provider Information | |||||||||
| NPI: | 1740269158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1405 MILL ST | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549612155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205312000 | ||||||||
| FaxNumber: | 9205312030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 387187-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 38187 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32248400 | 05 | WI | MEDICAID | 1009390 | 01 | WI | PHYS PLUS PROV # | OTHER | 70 | 01 | WI | DEANCARE PROV # | OTHER | 930117017 | 01 | WI | RAILROAD MEDICARE PROV # | OTHER |