Provider Demographics
NPI:1114125911
Name:MARIOLGA MERCADO DO PC
Entity Type:Organization
Organization Name:MARIOLGA MERCADO DO PC
Other - Org Name:MARI MERCADO, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIOLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-369-5505
Mailing Address - Street 1:1615 S EUCALYPTUS AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5990
Mailing Address - Country:US
Mailing Address - Phone:918-369-5505
Mailing Address - Fax:918-369-5508
Practice Address - Street 1:1615 S EUCALYPTUS AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5990
Practice Address - Country:US
Practice Address - Phone:918-369-5505
Practice Address - Fax:918-369-5508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI45372Medicare UPIN