Provider Demographics
NPI:1609828904
Name:MENDOZA, MANUEL R (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:R
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-6338
Mailing Address - Country:US
Mailing Address - Phone:956-698-5493
Mailing Address - Fax:956-698-4423
Practice Address - Street 1:1040 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-6338
Practice Address - Country:US
Practice Address - Phone:956-698-5493
Practice Address - Fax:956-698-4423
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXUE14654Medicare UPIN
TX86M993Medicare ID - Type Unspecified