Basic Information
| Provider Information | |||||||||
| NPI: | 1033101175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12600 PEMBROKE RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330272544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Practice Location | |||||||||
| Address1: | 12600 PEMBROKE RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330272544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 2014-00246 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | OS0007092 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207N00000X | OS7092 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 251021901 | 05 | FL | MEDICAID |