Healthcare Provider Details

I. General information

NPI: 1073807665
Provider Name (Legal Business Name): JEFFREY A. MENDOZA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11775 TECUMSEH CLINTON RD
CLINTON MI
49236-9541
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR PO BOX 0446 LOBBY J
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 517-456-7449
  • Fax: 517-456-6059
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116023323
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101021421
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: