=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114911245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELVIN M MENDEZ M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2005
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3410 TAMIAMI TRL A1
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-255-3722
-----------------------------------------------------
Fax | 941-255-3723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 511896
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33951-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-255-3722
-----------------------------------------------------
Fax | 941-255-3723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELVIN M MENDEZ
-----------------------------------------------------
Credential | M.D., P.A.
-----------------------------------------------------
Telephone | 941-255-3722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | ME64431
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------