Healthcare Provider Details

I. General information

NPI: 1760678676
Provider Name (Legal Business Name): PEDRO G MENDOZA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W CENTURY AVE
BISMARCK ND
58503-1401
US

IV. Provider business mailing address

300 W CENTURY AVE
BISMARCK ND
58503-1401
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-9900
  • Fax: 701-323-9911
Mailing address:
  • Phone: 701-323-9900
  • Fax: 701-323-9911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5553
License Number StateND

VIII. Authorized Official

Name: MS. SHAWNA D. ZASTOUPIL
Title or Position: DIRECTOR OF CODING/BILLING
Credential: R.H.I.T.
Phone: 701-323-9900