Provider Demographics
NPI:1306807029
Name:MENDEZ, EVELYN
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BLYTHE BLVD
Mailing Address - Street 2:MEDICAL CENTER PLAZA SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:MEDICAL CENTER PLAZA SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-02341208000000X, 2080P0206X, 208000000X
AZ401012080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ337612Medicaid
NC1306807029Medicaid
NC1306807029Medicaid
AZZ146252Medicare PIN
NCNCM127AMedicare PIN