Provider Demographics
NPI:1982714812
Name:MENDOZA, AMADO JOSE (PT)
Entity Type:Individual
Prefix:
First Name:AMADO
Middle Name:JOSE
Last Name:MENDOZA
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 1:1395 N COURTENAY PKWY
Mailing Address - Street 2:102
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4400
Mailing Address - Country:US
Mailing Address - Phone:321-986-8812
Mailing Address - Fax:
Practice Address - Street 1:1395 N COURTENAY PKWY
Practice Address - Street 2:102
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4400
Practice Address - Country:US
Practice Address - Phone:321-986-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892101600Medicaid
FLPT 9938OtherLICENSE #
FL892101600Medicaid