Provider Demographics
NPI:1588169627
Name:MENDES, DEMETRIUS
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:MENDES
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 1:190 GOLDEN ROD LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3651
Mailing Address - Country:US
Mailing Address - Phone:585-448-2895
Mailing Address - Fax:
Practice Address - Street 1:190 GOLDEN ROD LN
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3651
Practice Address - Country:US
Practice Address - Phone:585-448-2895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324681164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse