Provider Demographics
NPI:1669438651
Name:MENDOZA, TERESA M (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3319
Mailing Address - Country:US
Mailing Address - Phone:608-355-3800
Mailing Address - Fax:608-355-7001
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-355-3800
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37504-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000254OtherPHYSICIANS PLUS
WI5619OtherDEAN HEALTH INSURANCE
WI32205200Medicaid
WI000857145Medicare PIN
WI370020213Medicare PIN
WI32205200Medicaid