Healthcare Provider Details

I. General information

NPI: 1669870689
Provider Name (Legal Business Name): JORGE G. MENDEZ,MD. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CRESTFIELD RD
BOONTON NJ
07005-9007
US

IV. Provider business mailing address

9 CRESTFIELD RD
BOONTON NJ
07005-9007
US

V. Phone/Fax

Practice location:
  • Phone: 908-255-6200
  • Fax: 973-794-4261
Mailing address:
  • Phone: 908-255-6200
  • Fax: 973-794-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08542000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MA08542000
License Number StateNJ

VIII. Authorized Official

Name: DR. JORGE G. MENDEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 908-255-6200