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General NPI Number Information
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NPI Number | 1528387412
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE PRACTICE, LLC
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Dates
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Enumeration Date | 05/18/2010
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Last Update Date | 07/10/2015
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Provider Practice Location Address
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Address Line | 1011 E. NATIONAL AVE
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City | BRAZIL
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State | IN
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Zip | 47834
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Country | US
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Telephone | 812-446-3278
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Fax | 812-446-3508
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Provider Business Mailing Address
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Address Line | 1011 E. NATIONAL AVE
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City | BRAZIL
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State | IN
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Zip | 47834
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Country | US
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Telephone | 812-446-3278
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Fax | 812-446-3508
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Authorized Official
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Title or Position | DOCTOR
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Name | CAMILLO M MENDOZA
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Credential | MD
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Telephone | 812-446-3278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 01049698
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 01049692
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License Number State | IN
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