Provider Demographics
NPI:1104576164
Name:MENDEZ, OTONIEL
Entity type:Individual
Prefix:
First Name:OTONIEL
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CARR 2 UNIT 1761
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-4081
Mailing Address - Country:US
Mailing Address - Phone:787-205-3838
Mailing Address - Fax:
Practice Address - Street 1:CENTRO MEDICO DE PUERTO RICO
Practice Address - Street 2:BARRIO MONACILLOS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00935-0001
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR17091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program