Healthcare Provider Details

I. General information

NPI: 1922056902
Provider Name (Legal Business Name): DELQUIS RAFAEL MENDOZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3073 PANTHERSVILLE ROAD PATIENTS ACCOUNTS OFFICE
DECATUR GA
30034
US

IV. Provider business mailing address

P.O. BOX 370407 PATIENT ACCOUNTS OFFICE
DECATUR GA
30034
US

V. Phone/Fax

Practice location:
  • Phone: 404-243-2100
  • Fax: 404-243-2159
Mailing address:
  • Phone: 404-243-2100
  • Fax: 404-243-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number040436
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: