Provider Demographics
NPI:1740224534
Name:VAZQUEZ MERCADO, JAYSON (MD)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:VAZQUEZ 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:APTO 409
Mailing Address - Street 2:CONDOMINIO PASEO DEL PRINCIPE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-843-5118
Mailing Address - Fax:787-848-5776
Practice Address - Street 1:8165 CALLE CONCORDIA STE 101
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1553
Practice Address - Country:US
Practice Address - Phone:787-843-5118
Practice Address - Fax:787-848-5776
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14309208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI-17942Medicare UPIN