Healthcare Provider Details

I. General information

NPI: 1508587064
Provider Name (Legal Business Name): OSCAR MENDOZA GONZALEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 10/01/2022
Certification Date: 10/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8875 NW 23RD ST
DORAL FL
33172-2419
US

IV. Provider business mailing address

4783 E 9TH CT
HIALEAH FL
33013-2025
US

V. Phone/Fax

Practice location:
  • Phone: 305-653-5155
  • Fax:
Mailing address:
  • Phone: 786-257-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: