=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790824522
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROLANDO A MENDOZA, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 787 37TH ST SUITE E-210
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-7305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-562-5232
-----------------------------------------------------
Fax | 772-562-0773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 787 37TH ST SUITE E-210
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-7305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-562-5232
-----------------------------------------------------
Fax | 772-562-0773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT-SECRETARY
-----------------------------------------------------
Name | GEMMA I MENDOZA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 772-562-5232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 0025811
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------