Provider Demographics
NPI:1861466021
Name:MENDOZA, RICO V I (MD)
Entity Type:Individual
Prefix:DR
First Name:RICO V
Middle Name:I
Last Name:MENDOZA
Suffix:
Gender:M
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:PO BOX 4276
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305-4276
Mailing Address - Country:US
Mailing Address - Phone:864-582-6858
Mailing Address - Fax:864-585-0999
Practice Address - Street 1:2030 N CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2796
Practice Address - Country:US
Practice Address - Phone:864-582-6858
Practice Address - Fax:864-585-0999
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23156207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC231564Medicaid
SC8688OtherMBPG'S
SC290014819OtherRAILROAD
SC231564Medicaid
G14240Medicare UPIN
G142403365Medicare PIN
SC8688OtherMBPG'S