Provider Demographics
NPI:1750491106
Name:MERCADO, O. KENT (DPM)
Entity Type:Individual
Prefix:
First Name:O.
Middle Name:KENT
Last Name:MERCADO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 THORNHILL DR
Mailing Address - Street 2:#100
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2793
Mailing Address - Country:US
Mailing Address - Phone:630-690-3338
Mailing Address - Fax:630-690-3488
Practice Address - Street 1:501 THORNHILL DR
Practice Address - Street 2:#100
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2793
Practice Address - Country:US
Practice Address - Phone:630-690-3338
Practice Address - Fax:630-690-3488
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004238213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004238Medicaid
IL60001691OtherBC/BS PROVIDER #
IL60001691OtherBC/BS PROVIDER #
ILT90733Medicare UPIN