Provider Demographics
NPI: | 1568695757 |
---|---|
Name: | MENDEZ, SALVADOR (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | SALVADOR |
Middle Name: | |
Last Name: | MENDEZ |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | SAL |
Other - Middle Name: | |
Other - Last Name: | MENDEZ |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | DO |
Mailing Address - Street 1: | 169 ASHLEY AVE RM 202 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29425-8905 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 956-618-4414 |
Mailing Address - Fax: | 956-618-4424 |
Practice Address - Street 1: | 169 ASHLEY AVE RM 202 |
Practice Address - Street 2: | |
Practice Address - City: | CHARLESTON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29425 |
Practice Address - Country: | US |
Practice Address - Phone: | 956-618-4414 |
Practice Address - Fax: | 956-618-4424 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-09-03 |
Last Update Date: | 2018-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | LL52074 | 207R00000X |
TX | PA06381 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 1568695757 | Other | NPI |
TX | 8L23619 | Medicare PIN |