Provider Demographics
NPI:1023728813
Name:MENDOZA, MARC A
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7236 EVANSTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-3625
Mailing Address - Country:US
Mailing Address - Phone:703-229-7541
Mailing Address - Fax:
Practice Address - Street 1:6805 INDUSTRIAL RD STE 3100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-4206
Practice Address - Country:US
Practice Address - Phone:703-256-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist