Healthcare Provider Details

I. General information

NPI: 1760681761
Provider Name (Legal Business Name): PHILLIP MENDOZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 BUSINESS PARK BLVD
ANCHORAGE AK
99503
US

IV. Provider business mailing address

4951 BUSINESS PARK BLVD
ANCHORAGE AK
99503-7174
US

V. Phone/Fax

Practice location:
  • Phone: 907-743-7200
  • Fax:
Mailing address:
  • Phone: 907-743-7200
  • Fax: 907-743-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR-0939
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60167455
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50669
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: