Provider Demographics
NPI:1205823796
Name:MENDOZA, GLENN J (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:J
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:95 GRASSLANDS RD
Mailing Address - Street 2:MUNGER PAVILION STE 120
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1652
Mailing Address - Country:US
Mailing Address - Phone:914-493-8558
Mailing Address - Fax:914-493-1488
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4817
Practice Address - Country:US
Practice Address - Phone:914-493-8558
Practice Address - Fax:914-493-1488
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1483382080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7414706Medicaid
NY00992998Medicaid
NYA63340Medicare UPIN
NY5176N1Medicare PIN