Provider Demographics
NPI:1548340615
Name:MENDOZA, DELFIN
Entity type:Individual
Prefix:
First Name:DELFIN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LAKEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 LAKEVIEW ST
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-1720
Practice Address - Country:US
Practice Address - Phone:917-513-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016411-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ28X51Medicare ID - Type Unspecified