Provider Demographics
NPI:1649683830
Name:MENDOZA, ROSA M (MD)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3947
Mailing Address - Country:US
Mailing Address - Phone:732-306-2303
Mailing Address - Fax:
Practice Address - Street 1:610 W 158TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-7104
Practice Address - Country:US
Practice Address - Phone:732-306-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289405-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine