Provider Demographics
NPI:1255627964
Name:MENDOZA, MARCO (MD)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:
Last Name:MENDOZA
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 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:
Practice Address - Street 1:973 MICA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7255
Practice Address - Country:US
Practice Address - Phone:775-783-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125059818207X00000X
NC2016-00148207X00000X
NV17066207X00000X
CAA149150207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1255627964Medicaid
SCNC2672Medicaid
SCNC2672Medicaid
NC0397730004Medicare NSC