Provider Demographics
NPI:1982227062
Name:MENDOZA, JAIRO ENRIGUE (MD)
Entity Type:Individual
Prefix:
First Name:JAIRO
Middle Name:ENRIGUE
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:360-493-4180
Practice Address - Street 1:1620 COOPER POINT RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5736
Practice Address - Country:US
Practice Address - Phone:360-486-6710
Practice Address - Fax:360-705-0269
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61469474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine