Provider Demographics
NPI:1992142558
Name:MENDOZA, JERALD AGUILA (PT)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:AGUILA
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DOSORIS LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1539
Mailing Address - Country:US
Mailing Address - Phone:516-609-9400
Mailing Address - Fax:
Practice Address - Street 1:717 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4534
Practice Address - Country:US
Practice Address - Phone:516-565-4370
Practice Address - Fax:516-565-2644
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist