Organization
DR. MENDOZA'S PEDIATRIC AND ADOLSCENT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EDGAR ALLEN MENDOZA MD (OWNER)
(606) 693-4800
Entity
Organization
Contact information
Practice address
424 JETT DR, JACKSON, KY 41339-9621
(606) 693-4800
(606) 693-4825
Mailing address
PO BOX 790, JACKSON, KY 41339-0790
(606) 693-4800
(606) 693-4825
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
33465
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
31000979
—
KY
Enumeration date
04/11/2008
Last updated
07/10/2014
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