Provider Demographics
NPI:1982871174
Name:MENDOZA OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:MENDOZA OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMUNDO
Authorized Official - Middle Name:G
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-475-2184
Mailing Address - Street 1:2411 E PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-5101
Mailing Address - Country:US
Mailing Address - Phone:619-475-2184
Mailing Address - Fax:
Practice Address - Street 1:2411 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-5101
Practice Address - Country:US
Practice Address - Phone:619-475-2184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OPT 8150T261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081500Medicaid
CAOP8150Medicare PIN
CAGU117AMedicare PIN
CASD0081500Medicaid