Provider Demographics
NPI:1215914148
Name:QUERUBIN P MENDOZA MD PA
Entity type:Organization
Organization Name:QUERUBIN P MENDOZA MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:QUERUBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-248-2700
Mailing Address - Street 1:5101 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6818
Mailing Address - Country:US
Mailing Address - Phone:813-248-2700
Mailing Address - Fax:813-248-2722
Practice Address - Street 1:5101 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6818
Practice Address - Country:US
Practice Address - Phone:813-248-2700
Practice Address - Fax:813-248-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74240207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL176468283681OtherHUMANA
FL22661OtherAVMED
FL1018644OtherCAREPLUS
FL274844400Medicaid
FLDE6354OtherRAILROAD MEDICARE
FL218908590OtherTRICARE
FL2250675OtherCIGNA
FL0118255OtherGHI
FL14363001OtherCITRUS HEALTH
FL1210679OtherAETNA
FL002620688002OtherUNITED HEALTHCARE
FL2504898OtherUNITED HEALTHCARE
FL2250675OtherCIGNA