MEDICARE: EDISON V MENDOZA DELA PENA

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	207Q00000X	Family Medicine Physician	D41521302250	IL

General Provider Information

NPI Number	:	1659030195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDISON V MENDOZA DELA PENA

Provider Business Mailing Address
First Line	:	9429 BAY COLONY DR APT 1S
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-3623
Country	:	US
Telephone Number	:	224-619-0724
Fax Number	:

Provider Business Practice Location Address
First Line	:	9429 BAY COLONY DR
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-3623
Country	:	US
Telephone Number	:	224-619-0724
Fax Number	:

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

Provider Enumeration Date	:	12/13/2021
Last Update Date	:	12/13/2021

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Directions to “ EDISON V MENDOZA DELA PENA ” Practice Location

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