Provider Demographics
NPI:1326023839
Name:EXTRA-MENDOZA, EDITA (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITA
Middle Name:
Last Name:EXTRA-MENDOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5055 E BROADWAY BLVD
Mailing Address - Street 2:SUITE A100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711
Mailing Address - Country:US
Mailing Address - Phone:520-382-1205
Mailing Address - Fax:520-795-0225
Practice Address - Street 1:1055 N. LA CANADA BLVD
Practice Address - Street 2:SUITE 121
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614
Practice Address - Country:US
Practice Address - Phone:520-547-7770
Practice Address - Fax:520-547-7775
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ24412207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ449787Medicaid
AZZ145043OtherMEDICARE PTAN
AZZ145043OtherMEDICARE PTAN
G34374Medicare UPIN