Provider Demographics
NPI:1609825132
Name:MENDOZA, PEDRO G (MD FCCP)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:G
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1401
Mailing Address - Country:US
Mailing Address - Phone:701-323-9900
Mailing Address - Fax:701-323-9911
Practice Address - Street 1:300 W CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1401
Practice Address - Country:US
Practice Address - Phone:701-323-9900
Practice Address - Fax:701-323-9911
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5553207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15689Medicaid
NDN712611OtherMEDICARE SOLO #
ND12293OtherMEDICIAD GROUP NUMBER
ND22774OtherBCBS OF ND
NDB48075Medicare UPIN
ND12293OtherMEDICIAD GROUP NUMBER