Basic Information
| Provider Information | |||||||||
| NPI: | 1164477980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | CARVAJAL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENDOZA | ||||||||
| OtherFirstName: | JULITA | ||||||||
| OtherMiddleName: | CARVAJAL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 SAWGRASS CORPORATE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 9548580404 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 W. DR. MLK JR. BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138794730 | ||||||||
| FaxNumber: | 9548580404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 01039053 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 279968500 | 05 | FL | MEDICAID | 200198930 | 05 | IN | MEDICAID | 0859334 | 05 | OH | MEDICAID | 3495805 | 05 | MI | MEDICAID |