Provider Demographics
NPI:1578821195
Name:MEJIA, CARLOS R
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:MEJIA
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 1:724 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-1702
Mailing Address - Country:US
Mailing Address - Phone:570-599-4008
Mailing Address - Fax:
Practice Address - Street 1:724 W 20TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-1702
Practice Address - Country:US
Practice Address - Phone:570-599-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29880670172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver