Provider Demographics
NPI:1619219052
Name:MENDONCA, SHAWN JAMES (MD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:JAMES
Last Name:MENDONCA
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 1:2296 OPITZ BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3346
Mailing Address - Country:US
Mailing Address - Phone:703-680-2111
Mailing Address - Fax:703-878-3939
Practice Address - Street 1:2296 OPITZ BLVD STE 350
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3346
Practice Address - Country:US
Practice Address - Phone:703-680-2111
Practice Address - Fax:703-878-3939
Is Sole Proprietor?:No
Enumeration Date:2013-03-24
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297137208800000X
PAMD471068208800000X
VA0101280217208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY297137OtherLICENSE