Provider Demographics
NPI:1558368605
Name:MENDOZA, EVELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23278 KENT CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5086
Mailing Address - Country:US
Mailing Address - Phone:951-461-6653
Mailing Address - Fax:
Practice Address - Street 1:301 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3113
Practice Address - Country:US
Practice Address - Phone:951-766-6460
Practice Address - Fax:951-766-6459
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48611174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1062719OtherCLIA NUMBER
CA5945420003OtherMEDICARE PART D DME
CA5945420004OtherMEDICARE PART D DME
CA1225222029OtherMEDICARE PART B DME
CA00A486110Medicaid
CA1457545840OtherMEDICARE PART B DME
CA1558555938OtherMEDICARE PART B DME
CA330643850OtherTAX INDENTIFICATION NUMBE
CA5945420001OtherMEDICARE PART D DME
CA1962696344OtherMEDICARE PART B DME
CA5945420002OtherMEDICARE PART D DME
CA1558555938OtherMEDICARE PART B DME
CA330643850OtherTAX INDENTIFICATION NUMBE