Provider Demographics
NPI:1225096787
Name:MENDOZA, WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
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 1:2725 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2310
Mailing Address - Country:US
Mailing Address - Phone:850-897-9106
Mailing Address - Fax:850-650-8820
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:205-437-5998
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83187207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL059184923OtherBCBS PROVIDER NUMBER
FL03176OtherBCBS
AL059184924OtherBCBS PROVIDER NUMBER
FL262309900Medicaid
FL03176OtherBCBS
FL03176YMedicare PIN
AL059184923OtherBCBS PROVIDER NUMBER
FL03176EMedicare PIN