Provider Demographics
NPI:1679595631
Name:MENDIOLA, PAULA REBECCA (DO)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:REBECCA
Last Name:MENDIOLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:PAULA
Other - Middle Name:REBECCA
Other - Last Name:MENDIOLA-VOGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1024 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2776
Mailing Address - Country:US
Mailing Address - Phone:208-365-2338
Mailing Address - Fax:208-365-0677
Practice Address - Street 1:1024 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2776
Practice Address - Country:US
Practice Address - Phone:208-365-2338
Practice Address - Fax:208-365-0677
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60067853208600000X
IDO-0674208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COH65836Medicare UPIN