Provider Demographics
NPI:1780683979
Name:MENDZEF, SCOTT D (NP)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:MENDZEF
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 STATE ROUTE 31
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8715
Mailing Address - Country:US
Mailing Address - Phone:315-752-0141
Mailing Address - Fax:315-752-0142
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 4J
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-701-2170
Practice Address - Fax:315-701-2186
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301516363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01951688Medicaid
P00683925Medicare PIN
NYS82811Medicare ID - Type Unspecified
NY01951688Medicaid
NYCC4099Medicare UPIN
RB7372Medicare PIN