Provider Demographics
NPI:1619903218
Name:MENDOZA-AYALA, RAUL (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:MENDOZA-AYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAUL
Other - Middle Name:
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-288-8000
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42580207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104386082Medicaid
WI34036200Medicaid
WI290013377OtherRAILROAD
WI290013377OtherRAILROAD
WIG33107Medicare UPIN
WI34036200Medicaid