Healthcare Provider Details

I. General information

NPI: 1225227051
Provider Name (Legal Business Name): LENNY TUA MENDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 US HIGHWAY 98 S STE 102
LAKELAND FL
33812-4334
US

IV. Provider business mailing address

6675 WESTWOOD BLVD STE 475
ORLANDO FL
32821-6027
US

V. Phone/Fax

Practice location:
  • Phone: 863-646-9191
  • Fax: 863-646-5252
Mailing address:
  • Phone: 78-450-3304
  • Fax: 889-721-7528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16894
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: