Provider Demographics
NPI:1225212335
Name:MENDES MEDICAL ASSOC. PC
Entity Type:Organization
Organization Name:MENDES MEDICAL ASSOC. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:MENDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-327-7465
Mailing Address - Street 1:55 BELGRADE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2413
Mailing Address - Country:US
Mailing Address - Phone:617-327-7465
Mailing Address - Fax:617-363-9993
Practice Address - Street 1:55 BELGADE AVE
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2413
Practice Address - Country:US
Practice Address - Phone:617-327-7465
Practice Address - Fax:617-363-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
80176207R00000X
MA80176207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9729259Medicaid
MAM19669OtherBCBS
MA110069096AMedicaid
MA110069096AMedicaid
MAM19669OtherBCBS