Healthcare Provider Details

I. General information

NPI: 1073839759
Provider Name (Legal Business Name): MENDOZA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 WILLIAMS BLVD
KENNER LA
70065
US

IV. Provider business mailing address

3100 WILLIAMS BLVD
KENNER LA
70065-4505
US

V. Phone/Fax

Practice location:
  • Phone: 504-443-1744
  • Fax:
Mailing address:
  • Phone: 504-443-1744
  • Fax: 504-443-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO CLEMENTE MENDOZA
Title or Position: OWNER
Credential: M.D
Phone: 504-443-1744