Provider Demographics
NPI:1326063876
Name:MERCADO, ANGEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:J
Last Name:MERCADO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 FALCON RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-4772
Mailing Address - Country:US
Mailing Address - Phone:937-657-2132
Mailing Address - Fax:
Practice Address - Street 1:1679 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3336
Practice Address - Country:US
Practice Address - Phone:937-258-1515
Practice Address - Fax:937-258-8790
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000330235OtherANTHEM
OHME0864422Medicare ID - Type Unspecified
OHU73200Medicare UPIN