Provider Demographics
NPI:1356605877
Name:MENDOZA URIAS, GERONIMO (MD)
Entity type:Individual
Prefix:DR
First Name:GERONIMO
Middle Name:
Last Name:MENDOZA URIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GERONIMO
Other - Middle Name:
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:721 E HOLLY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-5245
Mailing Address - Country:US
Mailing Address - Phone:575-546-6010
Mailing Address - Fax:575-546-4099
Practice Address - Street 1:721 E HOLLY ST
Practice Address - Street 2:SUITE B
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-5245
Practice Address - Country:US
Practice Address - Phone:575-546-6010
Practice Address - Fax:575-546-4099
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10043455390200000X
NMMD2015-0230208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26393Medicaid