Healthcare Provider Details

I. General information

NPI: 1982227062
Provider Name (Legal Business Name): JAIRO ENRIGUE MENDOZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 COOPER POINT RD SW
OLYMPIA WA
98502-5736
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-6710
  • Fax: 360-705-0269
Mailing address:
  • Phone:
  • Fax: 360-493-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61469474
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: