Healthcare Provider Details

I. General information

NPI: 1578533659
Provider Name (Legal Business Name): JOSE E MENDOZA III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 NAGEL RD STE 500
AVON OH
44011-6401
US

IV. Provider business mailing address

PO BOX 636643
CINCINNATI OH
45263-6461
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-4600
  • Fax: 440-937-4605
Mailing address:
  • Phone: 440-989-3801
  • Fax: 440-960-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35-06-6480-M
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35066480
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: