Provider Demographics
NPI:1861674392
Name:LEONARDO C MENDOZA MD. INC
Entity Type:Organization
Organization Name:LEONARDO C MENDOZA MD. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:CESAR
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-843-2776
Mailing Address - Street 1:3310 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4219
Mailing Address - Country:US
Mailing Address - Phone:419-389-5909
Mailing Address - Fax:
Practice Address - Street 1:4352 W SYLVANIA AVE
Practice Address - Street 2:SUITE L
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3463
Practice Address - Country:US
Practice Address - Phone:419-843-2776
Practice Address - Fax:419-841-2698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35032912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0167653Medicaid
OH9371921Medicare PIN
OH0167653Medicaid