Provider Demographics
NPI:1447737358
Name:MENDOZA ORTIZ, JUAN RAFAEL
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:RAFAEL
Last Name:MENDOZA ORTIZ
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:I11 CALLE 3
Mailing Address - Street 2:URB ALTOS DE LA FUENTE
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726
Mailing Address - Country:US
Mailing Address - Phone:787-633-2456
Mailing Address - Fax:
Practice Address - Street 1:I11 CALLE 3
Practice Address - Street 2:URB ALTOS DE LA FUENTE
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-633-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080147207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program