1932155769 NPI number — MR. BYRON R MENDENHALL MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932155769 NPI number — MR. BYRON R MENDENHALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDENHALL
Provider First Name:
BYRON
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932155769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95267-0096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-956-7725
Provider Business Mailing Address Fax Number:
209-956-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W MINERAL KING
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISALIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-624-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  A41555 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A415550 . This is a "BS OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A415550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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