Provider Demographics
NPI:1437294881
Name:MENDIOLAZA, JESUS (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:
Last Name:MENDIOLAZA
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 1:1818 N MEADE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3454
Mailing Address - Country:US
Mailing Address - Phone:920-731-8900
Mailing Address - Fax:920-738-5369
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-731-8900
Practice Address - Fax:920-738-5369
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07917800207RC0000X
FLME0099005207RC0000X
IL036159510207RC0000X
WAMD61300184207RC0000X
WI3800207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278818700Medicaid
FL278818700Medicaid