Provider Demographics
NPI:1699813741
Name:MENDOZA, EDWARD MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MARTIN
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3556 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9520
Mailing Address - Country:US
Mailing Address - Phone:706-860-4527
Mailing Address - Fax:706-860-5433
Practice Address - Street 1:3556 PEBBLE BEACH DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-9520
Practice Address - Country:US
Practice Address - Phone:706-860-4527
Practice Address - Fax:706-860-5433
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0162612084N0400X
VA01012684252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology