Healthcare Provider Details

I. General information

NPI: 1093758666
Provider Name (Legal Business Name): MARC L. MENDES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR EMERGENCY DEPARTMENT
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

4126 ALEMAN DR
TARZANA CA
91356-5404
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-6101
  • Fax:
Mailing address:
  • Phone: 818-757-0457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA78160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: