Provider Demographics
NPI:1255324372
Name:MENDOZA LATTES, SERGIO A (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:A
Last Name:MENDOZA LATTES
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 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:800-782-6945
Mailing Address - Fax:
Practice Address - Street 1:40 DUKE MEDICINE CIR
Practice Address - Street 2:CLINIC 1B/1C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-4000
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IASP135207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA41986OtherWELLMARK BCBS
IA0245662Medicaid
IA41986OtherWELLMARK BCBS
IAI3955Medicare PIN
IA0245662Medicaid