Provider Demographics
NPI:1740269158
Name:MENDOZA, MANUEL A (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1539
Mailing Address - Country:US
Mailing Address - Phone:608-356-1400
Mailing Address - Fax:
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2000
Practice Address - Fax:920-531-2030
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI387187-020207Q00000X
WI38187207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32248400Medicaid
WI1009390OtherPHYS PLUS PROV #
WI70OtherDEANCARE PROV #
WI930117017OtherRAILROAD MEDICARE PROV #
WI1009390OtherPHYS PLUS PROV #
WI930117017OtherRAILROAD MEDICARE PROV #