Provider Demographics
NPI:1740202456
Name:MENDEZ, MICHELLE RENAE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENAE
Other - Last Name:EDSROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 440055
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-0001
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-282-1550
Practice Address - Street 1:1909 BEACH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-8608
Practice Address - Country:US
Practice Address - Phone:904-246-2752
Practice Address - Fax:904-246-2758
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00369612OtherMEDICARE RAILROAD
FL268106400Medicaid
FLH97404Medicare UPIN
FL29114YMedicare PIN