Provider Demographics
NPI:1144396854
Name:MENDOZA, TEODULO M (MD)
Entity Type:Individual
Prefix:
First Name:TEODULO
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 E LANDIS AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361
Mailing Address - Country:US
Mailing Address - Phone:856-696-6431
Mailing Address - Fax:856-794-5803
Practice Address - Street 1:1676 E LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361
Practice Address - Country:US
Practice Address - Phone:856-696-6431
Practice Address - Fax:856-794-5803
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO3146800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ117546B1HOtherMEDICARE BILLING ID
NJ4474201Medicaid
NJ4474201Medicaid