Provider Demographics
NPI:1760634984
Name:MERCADO JIMENEZ, GLORIA M
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:MERCADO JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:M
Other - Last Name:MERCADO JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:HC02 BOX 9879
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678
Mailing Address - Country:US
Mailing Address - Phone:787-895-6216
Mailing Address - Fax:
Practice Address - Street 1:CARR. #2 KM 96.8
Practice Address - Street 2:BO. COCOS
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678
Practice Address - Country:US
Practice Address - Phone:787-895-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR893291U00000X
PR09-F-06743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR31131Medicare PIN