Healthcare Provider Details

I. General information

NPI: 1568458149
Provider Name (Legal Business Name): QUERUBIN POLOCARPIO MENDOZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 N HABANA AVE
TAMPA FL
33614-6818
US

IV. Provider business mailing address

5101 N HABANA AVE
TAMPA FL
33614-6818
US

V. Phone/Fax

Practice location:
  • Phone: 813-248-2700
  • Fax: 813-248-2722
Mailing address:
  • Phone: 813-248-2700
  • Fax: 813-248-2722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME0074240
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME74240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: