Healthcare Provider Details

I. General information

NPI: 1871525592
Provider Name (Legal Business Name): SAMUEL ALLEN MENDOZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD RM A793
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

2215 FULLER RD RM A793
ANN ARBOR MI
48105-2303
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-3471
  • Fax:
Mailing address:
  • Phone: 734-845-3471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number4301084783
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: