Provider Demographics
NPI:1205165503
Name:HENRY P MENDOZA MD PC
Entity type:Organization
Organization Name:HENRY P MENDOZA MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-732-0020
Mailing Address - Street 1:2239 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5412
Mailing Address - Country:US
Mailing Address - Phone:810-732-0020
Mailing Address - Fax:810-732-7937
Practice Address - Street 1:2239 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5412
Practice Address - Country:US
Practice Address - Phone:810-732-0020
Practice Address - Fax:810-732-7937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0258594OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI1015680Medicaid
MI1015680Medicaid
MI0258594Medicare PIN