Provider Demographics
NPI:1174121289
Name:MENDOZA, LILIA M
Entity type:Individual
Prefix:
First Name:LILIA
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15324 SW 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1442
Mailing Address - Country:US
Mailing Address - Phone:305-607-2807
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-666-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine