Provider Demographics
NPI:1184696387
Name:MENA, JUAN CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:MENA
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 1:4411 THE 25 WAY NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-332-6900
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-6900
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM200507162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM600521002OtherMEDICARE IDTF
NM800521226OtherMEDICARE IDTF
NM2258272OtherMEDICARE GROUP
NM700521102OtherMEDICARE GROUP
NM45138Medicaid
NM52713Medicaid
NM68071019Medicaid
LA1492060Medicaid
NML0634Medicaid
NM2258272OtherMEDICARE GROUP
NML0634Medicaid
NM342534301Medicare PIN
TX8L7850Medicare PIN