Provider Demographics
NPI:1649408667
Name:MERCADO, MARISSA MARICEL ARMAMENTO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA MARICEL
Middle Name:ARMAMENTO
Last Name:MERCADO
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:26 W JACKSON COMMONS DR
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-1897
Practice Address - Country:US
Practice Address - Phone:770-848-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20208I2361OtherMEDICARE PTAN#
GA003124550AMedicaid