Basic Information
Provider Information
NPI: 1003800939
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MENDEZ
FirstName: ELVIN
MiddleName: M
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2147
Address2:  
City: FORT MYERS
State: FL
PostalCode: 339022147
CountryCode: US
TelephoneNumber: 9412553722
FaxNumber: 9412553723
Practice Location
Address1: 22655 BAYSHORE RD
Address2: STE 130
City: PORT CHARLOTTE
State: FL
PostalCode: 339802005
CountryCode: US
TelephoneNumber: 9412553722
FaxNumber: 9412553723
Other Information
ProviderEnumerationDate: 09/07/2005
LastUpdateDate: 09/25/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/25/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207K00000XME64431FLY Allopathic & Osteopathic PhysiciansAllergy & Immunology 

ID Information
IDTypeStateIssuerDescription
4786101FLBCBSOTHER
01428790005FL MEDICAID


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