Provider Demographics
NPI:1336217736
Name:MENDJUK, NICKOLAUS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAUS
Middle Name:
Last Name:MENDJUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KAISER PERMANENTE MID ATLANTIC PERMANENTE GROUP PC
Mailing Address - Street 2:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6W
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:WEST END MEDICAL CENTER
Practice Address - Street 2:2100 W PENNSYLVANIA AVE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-872-7232
Practice Address - Fax:202-872-7212
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101032769207R00000X
DCMD3540207R00000X
MDD14888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B94967Medicare UPIN
007645M92Medicare ID - Type Unspecified