Provider Demographics
NPI:1700888997
Name:MENDOZA, DOUGLAS K (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
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 1:9001 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3726
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5538
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021620207RC0000X
LAMD021620207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1660400Medicaid
MS00124748Medicaid
MS00588343Medicaid
G15572Medicare UPIN
LA5E6986629Medicare PIN
LA5E698Medicare PIN
MS00588343Medicaid