Provider Demographics
NPI:1306887328
Name:MENDOZA, LUIS E (DPM)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:E
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804
Mailing Address - Country:US
Mailing Address - Phone:708-780-8661
Mailing Address - Fax:708-231-9818
Practice Address - Street 1:5610 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804
Practice Address - Country:US
Practice Address - Phone:708-780-8661
Practice Address - Fax:708-231-9818
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004474213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004474Medicaid
IL212573Medicare PIN
IL016004474Medicaid