Healthcare Provider Details

I. General information

NPI: 1669768297
Provider Name (Legal Business Name): WALTER DEQUILLO MENDOZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 POST OAK PLACE DR
HOUSTON TX
77027-3164
US

IV. Provider business mailing address

4545 POST OAK PLACE DR
HOUSTON TX
77027-3164
US

V. Phone/Fax

Practice location:
  • Phone: 713-960-8008
  • Fax: 713-960-0965
Mailing address:
  • Phone: 713-960-8008
  • Fax: 713-960-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ2024
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: