Provider Demographics
NPI:1528387412
Name:INTERNAL MEDICINE PRACTICE, LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLO
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-446-3278
Mailing Address - Street 1:1011 E. NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834
Mailing Address - Country:US
Mailing Address - Phone:812-446-3278
Mailing Address - Fax:812-446-3508
Practice Address - Street 1:1011 E. NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834
Practice Address - Country:US
Practice Address - Phone:812-446-3278
Practice Address - Fax:812-446-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049692207R00000X
IN01049698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty