Provider Demographics
NPI:1780644161
Name:MENDOZA, CONCHITA (MD)
Entity Type:Individual
Prefix:
First Name:CONCHITA
Middle Name:
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 1:53 PARK PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3207
Mailing Address - Country:US
Mailing Address - Phone:347-921-3623
Mailing Address - Fax:718-638-1070
Practice Address - Street 1:270 9TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3906
Practice Address - Country:US
Practice Address - Phone:347-921-3623
Practice Address - Fax:718-638-1070
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141898207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01448824Medicaid
NY01448824Medicaid
59A712Medicare ID - Type Unspecified