Healthcare Provider Details

I. General information

NPI: 1740348317
Provider Name (Legal Business Name): PRUDENCIO MENDEZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINGSBOROUGH SQ SUITE A
CHESAPEAKE VA
23320-4988
US

IV. Provider business mailing address

1412 FENTRESS RD
CHESAPEAKE VA
23322-3930
US

V. Phone/Fax

Practice location:
  • Phone: 757-362-2529
  • Fax:
Mailing address:
  • Phone: 757-362-2529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101-040834
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: