Healthcare Provider Details

I. General information

NPI: 1740468685
Provider Name (Legal Business Name): ROBERT MENNIS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W I ST
LOS BANOS CA
93635-3419
US

IV. Provider business mailing address

PO BOX 2128
MERCED CA
95344-0128
US

V. Phone/Fax

Practice location:
  • Phone: 209-826-0591
  • Fax:
Mailing address:
  • Phone: 209-723-4849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC33289
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERT MENNIS
Title or Position: MD/OWNER
Credential: MD
Phone: 305-798-4388