Provider Demographics
NPI:1023578234
Name:BA MENDOZA, CALEB (DO)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:BA MENDOZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1888 HOLLYWOOD RD NW UNIT 6404
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-3687
Mailing Address - Country:US
Mailing Address - Phone:832-287-7133
Mailing Address - Fax:
Practice Address - Street 1:4181 HOSPITAL DR NE STE 303
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2541
Practice Address - Country:US
Practice Address - Phone:770-787-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100229208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery