Provider Demographics
NPI:1740404078
Name:MERCADO, VICENTE (PT)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:MERCADO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 CONROY RD
Mailing Address - Street 2:UNIT 221
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3765
Mailing Address - Country:US
Mailing Address - Phone:407-426-8677
Mailing Address - Fax:407-426-8677
Practice Address - Street 1:405 SOUTH SUMMIT ST.
Practice Address - Street 2:UNIT F
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112
Practice Address - Country:US
Practice Address - Phone:386-698-4720
Practice Address - Fax:386-698-4866
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist