1215914148 NPI number — QUERUBIN P MENDOZA MD PA

Table of content: (NPI 1215914148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215914148 NPI number — QUERUBIN P MENDOZA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUERUBIN P MENDOZA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1215914148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5101 N HABANA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33614-6818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-248-2700
Provider Business Mailing Address Fax Number:
813-248-2722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5101 N HABANA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33614-6818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-248-2700
Provider Business Practice Location Address Fax Number:
813-248-2722
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MENDOZA
Authorized Official First Name:
QUERUBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
813-248-2700

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  ME74240 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207UN0901X , with the licence number: ME74240 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 176468283681 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 22661 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1018644 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274844400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE6354 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 218908590 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2250675 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0118255 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14363001 . This is a "CITRUS HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1210679 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002620688002 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2504898 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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