Provider Demographics
NPI:1023081395
Name:MENDOZA, CAMILLO M (MD)
Entity type:Individual
Prefix:DR
First Name:CAMILLO
Middle Name:M
Last Name:MENDOZA
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 1:1011 E NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-2713
Mailing Address - Country:US
Mailing Address - Phone:812-446-3278
Mailing Address - Fax:812-446-3508
Practice Address - Street 1:1011 E NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2713
Practice Address - Country:US
Practice Address - Phone:812-446-3278
Practice Address - Fax:812-446-3508
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049692A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200217540AMedicaid
IN200217540AMedicaid
IN855920LMedicare ID - Type Unspecified