Provider Demographics
NPI:1477520435
Name:MENDENHALL, MILTON T (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:T
Last Name:MENDENHALL
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 1:400 HEALTH PARK BLVD
Mailing Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5784
Mailing Address - Country:US
Mailing Address - Phone:904-819-4398
Mailing Address - Fax:904-819-4976
Practice Address - Street 1:400 HEALTH PARK BLVD
Practice Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-819-4398
Practice Address - Fax:904-819-4976
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME480342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272439100Medicaid
FL300029640OtherRAILROAD MEDICARE
FL300029640OtherRAILROAD MEDICARE
FL272439100Medicaid