Provider Demographics
NPI:1609013549
Name:MENDOZA, NICOLAS DAVID
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:DAVID
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:USS HAWAII (SSN 776)
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS HAWAII (SSN 776)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:860-433-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman