Healthcare Provider Details

I. General information

NPI: 1447737358
Provider Name (Legal Business Name): JUAN RAFAEL MENDOZA ORTIZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 E EMPIRE ST FL 2
BLOOMINGTON IL
61704-5402
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-7800
  • Fax: 309-556-7804
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036175617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: