Provider Demographics
NPI:1295908101
Name:DR. MENDOZA'S PEDIATRIC AND ADOLSCENT
Entity type:Organization
Organization Name:DR. MENDOZA'S PEDIATRIC AND ADOLSCENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-693-4800
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0790
Mailing Address - Country:US
Mailing Address - Phone:606-693-4800
Mailing Address - Fax:606-693-4825
Practice Address - Street 1:424 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9621
Practice Address - Country:US
Practice Address - Phone:606-693-4800
Practice Address - Fax:606-693-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY334652080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000979Medicaid