Provider Demographics
NPI:1821572041
Name:MENDEZ, JONATTAN I
Entity Type:Individual
Prefix:MR
First Name:JONATTAN
Middle Name:
Last Name:MENDEZ
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 FRANK B MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1106
Mailing Address - Country:US
Mailing Address - Phone:413-210-9760
Mailing Address - Fax:
Practice Address - Street 1:170 FARNUM DR
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2808
Practice Address - Country:US
Practice Address - Phone:413-210-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100020971394Medicaid