1558368605 NPI number — DR. EVELYN MENDOZA M.D.

Table of content: DR. EVELYN MENDOZA M.D. (NPI 1558368605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558368605 NPI number — DR. EVELYN MENDOZA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
EVELYN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558368605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23278 KENT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-5086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-461-6653
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N SAN JACINTO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMET
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92543-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-766-6460
Provider Business Practice Location Address Fax Number:
951-766-6459
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A48611 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05D1062719 . This is a "CLIA NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5945420003 . This is a "MEDICARE PART D DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5945420004 . This is a "MEDICARE PART D DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1225222029 . This is a "MEDICARE PART B DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A486110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457545840 . This is a "MEDICARE PART B DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1558555938 . This is a "MEDICARE PART B DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 330643850 . This is a "TAX INDENTIFICATION NUMBE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5945420001 . This is a "MEDICARE PART D DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1962696344 . This is a "MEDICARE PART B DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5945420002 . This is a "MEDICARE PART D DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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