Healthcare Provider Details

I. General information

NPI: 1265745491
Provider Name (Legal Business Name): MICHAEL VINCENT SANTOTOME MENDOZA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BOULEVARD NE STE 415
ATLANTA GA
30312-4210
US

IV. Provider business mailing address

285 BOULEVARD NE SUITE 415
ATLANTA GA
30312
US

V. Phone/Fax

Practice location:
  • Phone: 404-265-4400
  • Fax: 404-265-4452
Mailing address:
  • Phone: 404-265-4400
  • Fax: 404-265-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number073365
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number073365
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number073365
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: