Provider Demographics
NPI:1073700134
Name:MENDOZA FAMILY PRACTICE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MENDOZA FAMILY PRACTICE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:LUISA
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-720-9111
Mailing Address - Street 1:1303 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2205
Mailing Address - Country:US
Mailing Address - Phone:661-720-9111
Mailing Address - Fax:661-725-4689
Practice Address - Street 1:1303 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2205
Practice Address - Country:US
Practice Address - Phone:661-720-9111
Practice Address - Fax:661-725-4689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073700134Medicaid
CAZZZ31675ZMedicare PIN
CA1073700134Medicaid