Provider Demographics
NPI:1891796058
Name:MENDOZA, JOSE KIAMCO JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:KIAMCO
Last Name:MENDOZA
Suffix:JR
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 1:4502 HIGHWAY 951
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748-5103
Mailing Address - Country:US
Mailing Address - Phone:225-634-4820
Mailing Address - Fax:225-634-0489
Practice Address - Street 1:4502 HIGHWAY 951
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748-5103
Practice Address - Country:US
Practice Address - Phone:225-634-4820
Practice Address - Fax:225-634-0489
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023159208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1497371Medicaid
MS0542328Medicaid
LAP00020217OtherRAIL ROAD MEDICARE
LA1497371Medicaid
356236YJA2Medicare PIN
5E989CF34Medicare PIN