Provider Demographics
NPI:1689623001
Name:LAT, MERCEDES (MD)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:LAT
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 1:1 FAMILY PRACTICE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6449
Mailing Address - Country:US
Mailing Address - Phone:845-338-6400
Mailing Address - Fax:845-339-7288
Practice Address - Street 1:1 FAMILY PRACTICE DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6449
Practice Address - Country:US
Practice Address - Phone:845-339-9055
Practice Address - Fax:845-339-2310
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123826208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00542049Medicaid
NYA400107426Medicare PIN
NYC07928Medicare UPIN