Provider Demographics
NPI:1710121520
Name:MENDOZA, ENRIQUE (DPT)
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 WARING RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4405
Mailing Address - Country:US
Mailing Address - Phone:760-724-9000
Mailing Address - Fax:760-724-3686
Practice Address - Street 1:2204 S EL CAMINO REAL
Practice Address - Street 2:SUITE 102
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6306
Practice Address - Country:US
Practice Address - Phone:760-477-3150
Practice Address - Fax:760-754-6785
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA355032251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35503OtherCALIFORNIA LICENSE NUMBER
CACI933ZOtherMEDICARE PTAN
CACI933ZOtherMEDICARE PTAN