Provider Demographics
NPI:1780703538
Name:MENDOZA, WALTER ENRIQUE (DC)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ENRIQUE
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S LONG BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4345
Mailing Address - Country:US
Mailing Address - Phone:516-445-9343
Mailing Address - Fax:
Practice Address - Street 1:20817 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1546
Practice Address - Country:US
Practice Address - Phone:718-465-4500
Practice Address - Fax:718-479-6754
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010611111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU99058Medicare UPIN