Provider Demographics
NPI:1699757757
Name:MENDOZA, PHILLIP ROMERO (CO)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ROMERO
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 E ERICKSON DR
Mailing Address - Street 2:#104
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2838
Mailing Address - Country:US
Mailing Address - Phone:520-881-2312
Mailing Address - Fax:520-881-2315
Practice Address - Street 1:5375 E ERICKSON DR
Practice Address - Street 2:#104
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2838
Practice Address - Country:US
Practice Address - Phone:520-881-2312
Practice Address - Fax:520-881-2315
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCO3039222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist