Provider Demographics
NPI:1356605877
Name:MENDOZA URIAS, GERONIMO (MD)
Entity type:Individual
Prefix:DR
First Name:GERONIMO
Middle Name:
Last Name:MENDOZA URIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GERONIMO
Other - Middle Name:
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4121 SAN ANTONIO ST APT 1418
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-2495
Mailing Address - Country:US
Mailing Address - Phone:832-275-0789
Mailing Address - Fax:
Practice Address - Street 1:2559 MEDICAL DR STE D
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8704
Practice Address - Country:US
Practice Address - Phone:575-446-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV7580208000000X
NMMD2015-0230208000000X
TXBP10043455390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26393Medicaid