Provider Demographics
NPI:1396833281
Name:MENDIOLA, JOSE (PT)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:MENDIOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FLANAGAN WAY
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-3445
Mailing Address - Country:US
Mailing Address - Phone:732-819-0725
Mailing Address - Fax:
Practice Address - Street 1:150 FLANAGAN WAY
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-3445
Practice Address - Country:US
Practice Address - Phone:732-819-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00377800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ056909S30Medicare PIN
NJ056909QCBMedicare PIN