Provider Demographics
NPI:1184147449
Name:BROOKLYN SPINE AND SPORTS MEDICINE P.C.
Entity type:Organization
Organization Name:BROOKLYN SPINE AND SPORTS MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:443-255-5130
Mailing Address - Street 1:415 GRAND NEW YORK STREET
Mailing Address - Street 2:APT E1707
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 GRAND NEW YORK STREET
Practice Address - Street 2:APT E1707
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:443-255-5130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFM3317256OtherDEA NUMBER