Basic Information
| Provider Information | |||||||||
| NPI: | 1891059259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIZARRAGA MENDOZA | ||||||||
| FirstName: | KARLO | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 278984 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853417500 | ||||||||
| FaxNumber: | 5854619078 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 WESTFALL RD., BUILDING C | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853417500 | ||||||||
| FaxNumber: | 5854619078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2012 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 296519 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 296519 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.