Provider Demographics
NPI:1376508168
Name:MENENDEZ, ISABEL C (MD)
Entity Type:Individual
Prefix:
First Name:ISABEL
Middle Name:C
Last Name:MENENDEZ
Suffix:
Gender:F
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 849
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-0849
Mailing Address - Country:US
Mailing Address - Phone:361-985-1221
Mailing Address - Fax:314-747-1429
Practice Address - Street 1:115 NORTHSHORE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-4206
Practice Address - Country:US
Practice Address - Phone:361-985-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG64482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117907902Medicaid
TX300024438Medicare PIN
TX8F5634Medicare PIN
TX117907902Medicaid
TX85R076Medicare PIN