Healthcare Provider Details

I. General information

NPI: 1881995462
Provider Name (Legal Business Name): LORETA A MENDOZA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORETA GALUTERA M,D

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 1250 FOREST PARK MEDICAL CLINIC
ST,LOUIS MO
63117-1263
US

IV. Provider business mailing address

11845 CRESTA VERDE DR APTC
SAINT LOUIS MO
63146-4746
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-6600
  • Fax: 314-367-5982
Mailing address:
  • Phone: 314-997-5997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number34045
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: