Provider Demographics
NPI:1962586149
Name:MENDOZA, MICHAEL DALE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1448
Mailing Address - Country:US
Mailing Address - Phone:585-279-4800
Mailing Address - Fax:585-442-8319
Practice Address - Street 1:777 S CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1448
Practice Address - Country:US
Practice Address - Phone:585-279-4800
Practice Address - Fax:585-442-8319
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253937207Q00000X
IL036-113672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113672OtherSTATE OF ILLINOIS, DIVISION OF PROFESSIONAL REGULATION
CAA81066OtherMEDICAL BOARD OF CALIFORNIA
IL036113672OtherSTATE OF ILLINOIS, DIVISION OF PROFESSIONAL REGULATION
I28409Medicare UPIN