Provider Demographics
NPI:1750390506
Name:GONZALEZ, JUAN EUGENIO TODD MENDOZA (MD)
Entity type:Individual
Prefix:
First Name:JUAN EUGENIO
Middle Name:TODD MENDOZA
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN EUGENIO TODD
Other - Middle Name:M
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3707
Practice Address - Country:US
Practice Address - Phone:910-642-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19456207R00000X
NC2014-02013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750390506Medicaid
SC194569Medicaid
SCCC5830OtherRAILROAD MEDICARE
SCCJ2418OtherRAILROAD MEDICARE
SCGP5508Medicaid
SC9337Medicare PIN
SCCJ2418OtherRAILROAD MEDICARE
NC1750390506Medicaid
7212Medicare PIN
3255Medicare PIN