Provider Demographics
NPI:1790117893
Name:MENDIVIL, JASON MAX (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MAX
Last Name:MENDIVIL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 N MESA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-6104
Mailing Address - Country:US
Mailing Address - Phone:915-313-6300
Mailing Address - Fax:915-521-2028
Practice Address - Street 1:4646 N MESA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6104
Practice Address - Country:US
Practice Address - Phone:915-313-6300
Practice Address - Fax:915-521-2028
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2205213E00000X, 213ES0103X
332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358170402Medicaid