Provider Demographics
NPI:1780721258
Name:MENDOZA, JOSE M SR (OPT)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:M
Last Name:MENDOZA
Suffix:SR
Gender:M
Credentials:OPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:K4 CALLE 17
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-1628
Mailing Address - Country:US
Mailing Address - Phone:787-608-5284
Mailing Address - Fax:787-768-9271
Practice Address - Street 1:K4 CALLE 17
Practice Address - Street 2:JARDINES DE COUNTRY CLUB
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-1628
Practice Address - Country:US
Practice Address - Phone:787-608-5682
Practice Address - Fax:787-768-9271
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR91156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician