Provider Demographics
NPI:1285669630
Name:MENDOZA, EUGENIO L IV (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENIO
Middle Name:L
Last Name:MENDOZA
Suffix:IV
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 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-285-5600
Mailing Address - Fax:815-285-5601
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3116
Practice Address - Country:US
Practice Address - Phone:815-285-5600
Practice Address - Fax:815-285-5601
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL381220OtherMEDICARE GROUP NUMBER
IL381220OtherMEDICARE GROUP NUMBER