Provider Demographics
NPI:1568648897
Name:MENDOZA, TRICIA POBLETE (MD)
Entity Type:Individual
Prefix:MS
First Name:TRICIA
Middle Name:POBLETE
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 1:20 LADD STREET
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-205-2953
Mailing Address - Fax:603-433-6341
Practice Address - Street 1:333 BORTHWICK AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4198
Practice Address - Country:US
Practice Address - Phone:603-436-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2468742084P0800X
NH143882084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH14388OtherNH LICENSE
NY03061869Medicaid
NH3098096Medicaid