Provider Demographics
NPI:1225011950
Name:MENDOZA, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
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:PO BOX 1758
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07015-1758
Mailing Address - Country:US
Mailing Address - Phone:973-473-5151
Mailing Address - Fax:973-473-3331
Practice Address - Street 1:289 MONROE ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5209
Practice Address - Country:US
Practice Address - Phone:973-473-5151
Practice Address - Fax:973-473-3331
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02404700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0365301Medicaid
NJ0365301Medicaid
NJ441496TCMMedicare PIN