Provider Demographics
NPI:1659487999
Name:MENDOZA, ENRIQUE FLORES (MD)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:FLORES
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:F
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:305 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401
Mailing Address - Country:US
Mailing Address - Phone:605-622-5500
Mailing Address - Fax:605-622-5042
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401
Practice Address - Country:US
Practice Address - Phone:605-622-5500
Practice Address - Fax:605-622-5042
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD17762085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7201840Medicaid
605Medicare ID - Type Unspecified
D25472Medicare UPIN