=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972008035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNNY MENDOZA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 FORD ST
-----------------------------------------------------
City | OGDENSBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13669-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-713-9350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | A2 VILLA DEL CARMEN
-----------------------------------------------------
City | CABO ROJO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00623-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-599-0160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 341268
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------