Dr. Mendoza'S Pediatric and Adolscent

Primary specialty

Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X

License

33465 Issued in KY

Legal business name

DR. MENDOZA'S PEDIATRIC AND ADOLSCENT

Practice address

424 Jett Dr
Jackson, KY 41339-9621

Phone

(606) 693-4800

Fax

(606) 693-4825

NPI assigned

Apr 11, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Edgar Allen Mendoza, MD

Title

Owner

Phone

(606) 693-4800

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1207872000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1404950400000",
    "number": "1295908101",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 790",
            "city": "JACKSON",
            "state": "KY",
            "postal_code": "413390790",
            "telephone_number": "606-693-4800",
            "fax_number": "606-693-4825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "424 JETT DR",
            "city": "JACKSON",
            "state": "KY",
            "postal_code": "413399621",
            "telephone_number": "606-693-4800",
            "fax_number": "606-693-4825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DR. MENDOZA'S PEDIATRIC AND ADOLSCENT",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-11",
        "last_updated": "2014-07-10",
        "status": "A",
        "authorized_official_last_name": "MENDOZA",
        "authorized_official_first_name": "EDGAR",
        "authorized_official_middle_name": "ALLEN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "606-693-4800",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "KY",
            "license": "33465",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31000979",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Jackson, KY
• Pediatric Adolescent Medicine Physician in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.