Provider Demographics
NPI:1083265607
Name:MERCADO NEGRON, IDALIS (MPHE, CTTS, CHES)
Entity Type:Individual
Prefix:
First Name:IDALIS
Middle Name:
Last Name:MERCADO NEGRON
Suffix:
Gender:F
Credentials:MPHE, CTTS, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 AVE WINSTON CHURCHILL
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6013
Mailing Address - Country:US
Mailing Address - Phone:787-999-6200
Mailing Address - Fax:
Practice Address - Street 1:CALLE FELIPE DE PLANA #5
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-999-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1504225200000X
PR16160174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16160OtherCHES