Provider Demographics
NPI:1366304412
Name:MENDEZ, RYAN DERRICK
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DERRICK
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 BURT RD APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-6317
Mailing Address - Country:US
Mailing Address - Phone:786-379-9502
Mailing Address - Fax:
Practice Address - Street 1:5804 BURT RD APT A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-6317
Practice Address - Country:US
Practice Address - Phone:786-379-9502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCM532-724-95-413-0246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other