Healthcare Provider Details

I. General information

NPI: 1235126376
Provider Name (Legal Business Name): MYRA N MENDOZA O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 PHILADELPHIA ST
AMES IA
50010-8772
US

IV. Provider business mailing address

309 E CHURCH ST
MARSHALLTOWN IA
50158-2946
US

V. Phone/Fax

Practice location:
  • Phone: 515-663-4800
  • Fax: 515-232-3532
Mailing address:
  • Phone: 641-754-6262
  • Fax: 641-754-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT12839
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02361
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: