Provider Demographics
NPI:1104120351
Name:LEONARDO MENDEZ MD PC
Entity type:Organization
Organization Name:LEONARDO MENDEZ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-522-9090
Mailing Address - Street 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:SUITE 470
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3601
Mailing Address - Country:US
Mailing Address - Phone:703-522-9090
Mailing Address - Fax:703-522-9096
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:SUITE 470
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-522-9090
Practice Address - Fax:703-522-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052239261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6060609Medicaid
1164441408Medicare PIN
VA6060609Medicaid