Healthcare Provider Details

I. General information

NPI: 1255463592
Provider Name (Legal Business Name): SUSANA MARIBEL MENDOZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 W SUNSET BLVD 2ND FLOOR, NEPHROLOGY DEPARTMENT
LOS ANGELES CA
90027-6082
US

IV. Provider business mailing address

8920 MURIETTA AVE
PANORAMA CITY CA
91402-2628
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-5987
  • Fax:
Mailing address:
  • Phone: 310-903-1364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA87787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: