Healthcare Provider Details

I. General information

NPI: 1952627184
Provider Name (Legal Business Name): MANUEL MENDOZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 W RIVERSIDE DR
BURBANK CA
91505-4044
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-556-2700
  • Fax: 818-295-3450
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA119371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: