MEDICARE: JOSE KIAMCO MENDOZA JR. M.D.

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	208M00000X	Hospitalist Physician	023159	LA
2	207R00000X	Internal Medicine Physician	023159	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00020217	OTHER	LA	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891796058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE KIAMCO MENDOZA JR. M.D.

Provider Business Mailing Address
First Line	:	4502 HIGHWAY 951
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-5103
Country	:	US
Telephone Number	:	225-634-4820
Fax Number	:	225-634-0489

Provider Business Practice Location Address
First Line	:	4502 HIGHWAY 951
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-5103
Country	:	US
Telephone Number	:	225-634-4820
Fax Number	:	225-634-0489

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	11/02/2023

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