Provider Demographics
NPI:1659562395
Name:MEJIA, JOSE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:MEJIA
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 1:520 JEFFERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2538
Mailing Address - Country:US
Mailing Address - Phone:724-527-8060
Mailing Address - Fax:724-522-4002
Practice Address - Street 1:555 ROUTE 217
Practice Address - Street 2:SUITE 1
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-3428
Practice Address - Country:US
Practice Address - Phone:724-694-2723
Practice Address - Fax:724-694-8830
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD445892207Q00000X
PAMT197060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027279080001Medicaid
PA243462Medicare PIN