MEDICARE: DR. MICHAEL DALE MENDOZA MD, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	253937	NY
2	207Q00000X	Family Medicine Physician	036-113672	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036113672	OTHER	IL	STATE OF ILLINOIS, DIVISION OF PROFESSIONAL REGULATION
2	A81066	OTHER	CA	MEDICAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1962586149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DALE MENDOZA MD, MPH

Provider Business Mailing Address
First Line	:	777 S CLINTON AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-1448
Country	:	US
Telephone Number	:	585-279-4800
Fax Number	:	585-442-8319

Provider Business Practice Location Address
First Line	:	777 S CLINTON AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-1448
Country	:	US
Telephone Number	:	585-279-4800
Fax Number	:	585-442-8319

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/06/2023

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