Provider Demographics
NPI:1740348317
Name:MENDEZ, PRUDENCIO JR (MD)
Entity type:Individual
Prefix:DR
First Name:PRUDENCIO
Middle Name:
Last Name:MENDEZ
Suffix:JR
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 1:1412 FENTRESS RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-3930
Mailing Address - Country:US
Mailing Address - Phone:757-362-2529
Mailing Address - Fax:
Practice Address - Street 1:680 KINGSBOROUGH SQ
Practice Address - Street 2:SUITE A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4988
Practice Address - Country:US
Practice Address - Phone:757-362-2529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-040834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VABM0890815OtherDEA
VAB09768Medicare UPIN