Provider Demographics
NPI:1790779049
Name:MERCADO, JOSELITO LAUREL (PT)
Entity Type:Individual
Prefix:MR
First Name:JOSELITO
Middle Name:LAUREL
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:PO BOX 2467
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-2467
Mailing Address - Country:US
Mailing Address - Phone:318-398-9675
Mailing Address - Fax:318-398-9295
Practice Address - Street 1:100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-8537
Practice Address - Country:US
Practice Address - Phone:318-398-9675
Practice Address - Fax:318-398-9295
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01128F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5X641Medicare ID - Type UnspecifiedPART B