Healthcare Provider Details

I. General information

NPI: 1700847001
Provider Name (Legal Business Name): MA. CONCEPCION MENDOZA PRUDENCIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

IV. Provider business mailing address

PO BOX 44008 UFJP
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-359-3842
  • Fax: 904-359-3847
Mailing address:
  • Phone: 904-244-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME68745
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: