Provider Demographics
NPI:1588964464
Name:MENDOZA, JUAN ANTONIO (CPO)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6190 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3428
Mailing Address - Country:US
Mailing Address - Phone:619-285-5040
Mailing Address - Fax:619-285-5045
Practice Address - Street 1:6190 FAIRMOUNT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3428
Practice Address - Country:US
Practice Address - Phone:619-285-5040
Practice Address - Fax:619-285-5045
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter