1881995462 NPI number — DR. LORETA A MENDOZA M.D

Table of content: DR. LORETA A MENDOZA M.D (NPI 1881995462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881995462 NPI number — DR. LORETA A MENDOZA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
LORETA
Provider Middle Name:
A
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:
GALUTERA
Provider Other First Name:
LORETA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M,D
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1881995462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11845 CRESTA VERDE DR
Provider Second Line Business Mailing Address:
APTC
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-4746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-997-5997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1034 S BRENTWOOD BLVD STE 1250
Provider Second Line Business Practice Location Address:
FOREST PARK MEDICAL CLINIC
Provider Business Practice Location Address City Name:
ST,LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63117-1263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-367-6600
Provider Business Practice Location Address Fax Number:
314-367-5982
Provider Enumeration Date:
11/12/2010

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: 261QH0100X , with the licence number:  34045 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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