Healthcare Provider Details

I. General information

NPI: 1245770601
Provider Name (Legal Business Name): LUIS ALBERTO MENDOZA MORET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 FIVAY RD
HUDSON FL
34667-7103
US

IV. Provider business mailing address

11910 CASSANDRA ST UNIT 203
NEW PORT RICHEY FL
34654-1528
US

V. Phone/Fax

Practice location:
  • Phone: 727-819-2929
  • Fax:
Mailing address:
  • Phone: 787-365-6673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN27471
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: