Healthcare Provider Details

I. General information

NPI: 1215914148
Provider Name (Legal Business Name): QUERUBIN P MENDOZA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/20/2010
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 TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME74240
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME74240
License Number StateFL

VIII. Authorized Official

Name: DR. QUERUBIN MENDOZA
Title or Position: OWNER/MD
Credential: MD
Phone: 813-248-2700