Provider Demographics
NPI:1316101389
Name:MENDOZA, JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1960
Mailing Address - Country:US
Mailing Address - Phone:201-343-2277
Mailing Address - Fax:201-343-7410
Practice Address - Street 1:440 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-2302
Practice Address - Country:US
Practice Address - Phone:201-358-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09068600208100000X
NY2707562081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation