Provider Demographics
NPI:1447424627
Name:MENDOZA, MARIO ROBERTO
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:ROBERTO
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W MONROE ST
Mailing Address - Street 2:#309
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2565
Mailing Address - Country:US
Mailing Address - Phone:773-495-8005
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:773-495-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program