Provider Demographics
NPI:1558450510
Name:MENDOZA, DOMINADOR MANGUERA JR (MD)
Entity Type:Individual
Prefix:
First Name:DOMINADOR
Middle Name:MANGUERA
Last Name:MENDOZA
Suffix:JR
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 111
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:NC
Mailing Address - Zip Code:27016-0111
Mailing Address - Country:US
Mailing Address - Phone:336-539-8375
Mailing Address - Fax:336-593-8800
Practice Address - Street 1:1578 HWY 8 & 89
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:NC
Practice Address - Zip Code:27016-0111
Practice Address - Country:US
Practice Address - Phone:336-539-8375
Practice Address - Fax:336-593-8800
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22149174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8958615Medicaid
NC201888Medicare PIN
C80950Medicare UPIN