1336985886 NPI number — MS. INDIRA E MATUTE MENDOZA 610-P.A.

Table of content: MS. INDIRA E MATUTE MENDOZA 610-P.A. (NPI 1336985886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336985886 NPI number — MS. INDIRA E MATUTE MENDOZA 610-P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATUTE MENDOZA
Provider First Name:
INDIRA
Provider Middle Name:
E
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
610-P.A.
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:
1336985886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13072
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00908-3072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-631-5924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 AV. 65 DE INFANTERIA
Provider Second Line Business Practice Location Address:
SHOPPING COURT, 2ND FLOOR
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-200-7833
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/03/2024

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: 363AM0700X , with the licence number:  610-P.A. , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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