Provider Demographics
NPI:1033139100
Name:MERCADO, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MERCADO
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 1:1307 S. INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 2091
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1414
Mailing Address - Country:US
Mailing Address - Phone:407-771-0404
Mailing Address - Fax:407-771-0405
Practice Address - Street 1:1307 S INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 2091
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1413
Practice Address - Country:US
Practice Address - Phone:407-771-0404
Practice Address - Fax:407-771-0405
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 73229207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259497800Medicaid
FL35608Medicare PIN
FLG37545Medicare UPIN