Provider Demographics
NPI:1427016450
Name:MENDES, MICHAEL WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MENDES
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 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:330 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5630
Practice Address - Country:US
Practice Address - Phone:706-236-6426
Practice Address - Fax:706-236-6437
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057103207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA906139956EMedicaid
GA906139956EMedicaid
GAE21950Medicare UPIN