Basic Information
| Provider Information | |||||||||
| NPI: | 1710094255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307835 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 3581 HARRODSBURG RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405131140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593136300 | ||||||||
| FaxNumber: | 5946981858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 06/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34008 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64014509 | 05 | KY | MEDICAID |