Provider Demographics
NPI:1558706952
Name:MENDOZA, ALLAN D
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:D
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 1:4229 LAKE APACHE DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5821
Mailing Address - Country:US
Mailing Address - Phone:361-331-4464
Mailing Address - Fax:
Practice Address - Street 1:5758 TIMBERGATE DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:UT
Practice Address - Zip Code:78414
Practice Address - Country:US
Practice Address - Phone:361-215-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1095255172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker