Provider Demographics
NPI:1306912878
Name:MENDOZA, OLGA L (MD)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:L
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 NW 107TH AVE STE M
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2735
Mailing Address - Country:US
Mailing Address - Phone:786-238-7282
Mailing Address - Fax:833-927-2568
Practice Address - Street 1:1470 NW 107TH AVE STE M
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2735
Practice Address - Country:US
Practice Address - Phone:786-238-7282
Practice Address - Fax:833-927-2568
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1116208D00000X
PR14862208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
500454EOtherMMM
I00922Medicare UPIN
22137Medicare ID - Type Unspecified