Healthcare Provider Details

I. General information

NPI: 1174014880
Provider Name (Legal Business Name): MICHELLE ALEXANDRA MENDIOLA-PLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S FAIRFIELD AVE
CHICAGO IL
60608-1782
US

IV. Provider business mailing address

445 E OHIO ST APT 2117
CHICAGO IL
60611-3339
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6464
  • Fax:
Mailing address:
  • Phone: 310-746-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125072484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: