Provider Demographics
NPI:1376521997
Name:MERCADO, ISMAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ISMAEL
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:PO BOX 52217
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-2217
Mailing Address - Country:US
Mailing Address - Phone:787-785-4402
Mailing Address - Fax:787-995-0283
Practice Address - Street 1:CALLE 2 G-14
Practice Address - Street 2:EXT. VILLA RICA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-785-4402
Practice Address - Fax:787-995-0283
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14690208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR994518OtherMEDICARE
PR22195MEOtherSSS
I04201Medicare UPIN
PR002195Medicare ID - Type Unspecified