Provider Demographics
NPI:1376997502
Name:PERDOMO RODRIGUEZ, MERCY YARIELA (MD)
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:YARIELA
Last Name:PERDOMO RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 N MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2724
Mailing Address - Country:US
Mailing Address - Phone:352-634-4830
Mailing Address - Fax:505-272-4639
Practice Address - Street 1:1580 1ST ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2841
Practice Address - Country:US
Practice Address - Phone:707-258-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
IL0361591332084P0800X
CA1750572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM390200000XOtherSTUDENT
CA2084P0800XMedicaid