Provider Demographics
NPI:1356311138
Name:MENDIETA, JOSE M (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:MENDIETA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E LIBERTY ST
Mailing Address - Street 2:SUITE902
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1530
Mailing Address - Country:US
Mailing Address - Phone:502-587-9140
Mailing Address - Fax:502-587-9142
Practice Address - Street 1:250 E LIBERTY ST
Practice Address - Street 2:SUITE902
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1530
Practice Address - Country:US
Practice Address - Phone:502-587-9140
Practice Address - Fax:502-587-9142
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY24590207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100351690AMedicaid
KY64245905Medicaid
C65375Medicare UPIN
KY1475601Medicare ID - Type UnspecifiedSHELBYVILLE
IN100351690AMedicaid