Healthcare Provider Details

I. General information

NPI: 1710919246
Provider Name (Legal Business Name): CLYDE C MENDONCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 E WARNER RD SUITE 101
TEMPE AZ
85284-3493
US

IV. Provider business mailing address

2149 E WARNER RD SUITE 101
TEMPE AZ
85284-3494
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-8714
  • Fax: 480-464-0189
Mailing address:
  • Phone: 480-610-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number229265
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number40391
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: