=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710164371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENRIQUE SANCHEZ MENDEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2008
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 BICENTENNIAL WAY
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-393-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5778 OWL HILL AVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95409-4363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-904-3423
-----------------------------------------------------
Fax | 707-225-0921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A112138
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------