Provider Demographics
NPI:1518493980
Name:MENDOZA, JOSE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:MENDOZA
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:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-786-4133
Mailing Address - Fax:336-783-3417
Practice Address - Street 1:280 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2267
Practice Address - Country:US
Practice Address - Phone:336-786-4133
Practice Address - Fax:336-783-3417
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine