Provider Demographics
NPI:1982207866
Name:MITRA, MARIA ROSENDA MENDOZA
Entity Type:Individual
Prefix:
First Name:MARIA ROSENDA
Middle Name:MENDOZA
Last Name:MITRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-4219
Mailing Address - Country:US
Mailing Address - Phone:540-898-4523
Mailing Address - Fax:
Practice Address - Street 1:4501 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4219
Practice Address - Country:US
Practice Address - Phone:540-898-4523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist