Provider Demographics
NPI:1831127992
Name:SAN JOSE-CARLSON, NELIA MENDOZA (MD)
Entity Type:Individual
Prefix:
First Name:NELIA
Middle Name:MENDOZA
Last Name:SAN JOSE-CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NELIA
Other - Middle Name:MENDOZA
Other - Last Name:SAN JOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6000 HAMS CT
Mailing Address - Street 2:
Mailing Address - City:WOODFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22580-9646
Mailing Address - Country:US
Mailing Address - Phone:814-591-8455
Mailing Address - Fax:
Practice Address - Street 1:420 HUDGINS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4172
Practice Address - Country:US
Practice Address - Phone:814-591-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012456842084P0800X
PAMDO67980L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA008450693OtherHIGHMARK BC/BS
PA0017557270002Medicaid
PA5624399OtherFIRST HEALTH PROVIDER #
PA008450693OtherHIGHMARK BC/BS
PA5624399OtherFIRST HEALTH PROVIDER #