Healthcare Provider Details

I. General information

NPI: 1053482794
Provider Name (Legal Business Name): MAGDA DESIREE MENDEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

81 E CEDAR LN
TEANECK NJ
07666-5423
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5030
  • Fax:
Mailing address:
  • Phone: 201-837-7602
  • Fax: 718-579-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number225803
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: