Provider Demographics
NPI:1568458149
Name:MENDOZA, QUERUBIN POLOCARPIO (MD)
Entity Type:Individual
Prefix:
First Name:QUERUBIN
Middle Name:POLOCARPIO
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 1:5101 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6818
Mailing Address - Country:US
Mailing Address - Phone:813-248-2700
Mailing Address - Fax:813-248-2722
Practice Address - Street 1:5101 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6818
Practice Address - Country:US
Practice Address - Phone:813-248-2700
Practice Address - Fax:813-248-2722
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074240207RC0000X
FLME74240207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2504898OtherUNITED HEALTHCARE
FL14363001OtherCITRUS HEALTH
FL2250675OtherCIGNA
FL1210679OtherAETNA
FLDE6354OtherRR MEDICARE
FL254936100Medicaid
FL0118255OtherGHI
FL176468283681OtherHUMANA
FL22661OtherAVMED
FL1018644OtherCAREPLUS
FL42448OtherBLUE CROSS BLUE SHIELD
FL1210679OtherAETNA
FL1018644OtherCAREPLUS