Provider Demographics
NPI:1154439909
Name:MENDOZA, JOSE A (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-4000
Mailing Address - Fax:
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06122800207V00000X
PAMD453476207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6978304Medicaid
NJG30408Medicare UPIN
NJ6978304Medicaid