MEDICARE: JOHANN MENDEZ SPECIAL ED. TEACHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	693808	NY

General Provider Information

NPI Number	:	1083261523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANN MENDEZ SPECIAL ED. TEACHER

Provider Business Mailing Address
First Line	:	9452 MAGNOLIA CT # 1B
Second Line	:
City	:	OZONE PARK
State	:	NY
Zip	:	11417-2958
Country	:	US
Telephone Number	:	917-680-8252
Fax Number	:

Provider Business Practice Location Address
First Line	:	9452 MAGNOLIA CT # 1B
Second Line	:
City	:	OZONE PARK
State	:	NY
Zip	:	11417-2958
Country	:	US
Telephone Number	:	917-680-8252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2019
Last Update Date	:	08/20/2019

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