Provider Demographics
NPI:1619429404
Name:MENDOZA-PRADO, RAFAEL JACINTO (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:JACINTO
Last Name:MENDOZA-PRADO
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 1:205 E TORONTO AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1209
Mailing Address - Country:US
Mailing Address - Phone:956-687-6155
Mailing Address - Fax:
Practice Address - Street 1:205 E TORONTO AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1209
Practice Address - Country:US
Practice Address - Phone:956-687-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X, 390200000X
TXSA000718363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00718OtherTEXAS MEDKCAL BOARD LICENSE