Provider Demographics
NPI:1891891388
Name:MENDOZA, EDGAR A D (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:A D
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 690
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-0152
Practice Address - Street 1:1484 LAKESIDE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-6555
Practice Address - Country:US
Practice Address - Phone:606-666-9950
Practice Address - Fax:606-666-9136
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1467417691OtherMEDICAID FQHC GROUP
KY64343650Medicaid
KY64343650Medicaid