Provider Demographics
NPI:1336475060
Name:MENDOZA, EDSEL (RPT)
Entity Type:Individual
Prefix:MR
First Name:EDSEL
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 LINDBERGH BLVD
Mailing Address - Street 2:APT 1610
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-1536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8500 LINDBERGH BLVD
Practice Address - Street 2:APT 1610
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19153-1536
Practice Address - Country:US
Practice Address - Phone:267-407-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist