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General NPI Number Information
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NPI Number | 1295908101
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Entity Type | Organization
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Legal Business Name | DR. MENDOZA'S PEDIATRIC AND ADOLSCENT
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Dates
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Enumeration Date | 04/11/2008
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Last Update Date | 07/10/2014
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Provider Practice Location Address
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Address Line | 424 JETT DR
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City | JACKSON
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State | KY
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Zip | 41339-9621
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Country | US
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Telephone | 606-693-4800
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Fax | 606-693-4825
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Provider Business Mailing Address
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Address Line | PO BOX 790
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City | JACKSON
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State | KY
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Zip | 41339-0790
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Country | US
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Telephone | 606-693-4800
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Fax | 606-693-4825
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Authorized Official
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Title or Position | OWNER
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Name | EDGAR ALLEN MENDOZA
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Credential | MD
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Telephone | 606-693-4800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 33465
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License Number State | KY
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