1891059259 NPI number — KARLO JOHN LIZARRAGA MENDOZA MD, MS

Table of content: SCARLET CONSTANT M.D. (NPI 1497913131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891059259 NPI number — KARLO JOHN LIZARRAGA MENDOZA MD, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIZARRAGA MENDOZA
Provider First Name:
KARLO
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MS
Provider Gender Code:
M

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:
1891059259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 ELMWOOD AVE BOX 278984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14642-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-341-7500
Provider Business Mailing Address Fax Number:
585-461-9078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 WESTFALL RD., BUILDING C
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-2692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-341-7500
Provider Business Practice Location Address Fax Number:
585-461-9078
Provider Enumeration Date:
06/30/2012

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: 2084N0400X , with the licence number:  296519 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0600X , with the licence number: 296519 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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