Provider Demographics
NPI:1497211163
Name:MENDOZA, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:3070 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2310
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-471-5139
Practice Address - Street 1:1815 E VALLEY PKWY STE 5
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-2550
Practice Address - Country:US
Practice Address - Phone:760-233-9655
Practice Address - Fax:760-233-9648
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296496225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty