Healthcare Provider Details

I. General information

NPI: 1306912878
Provider Name (Legal Business Name): OLGA L. MENDOZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 NW 107TH AVE STE M
SWEETWATER FL
33172-2735
US

IV. Provider business mailing address

1470 NW 107TH AVE STE M
SWEETWATER FL
33172-2735
US

V. Phone/Fax

Practice location:
  • Phone: 786-238-7282
  • Fax: 833-927-2568
Mailing address:
  • Phone: 786-238-7282
  • Fax: 833-927-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1116
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14862
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: