Provider Demographics
NPI:1831126317
Name:ALEX J. MERCANDETTI, M.D., INC. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ALEX J. MERCANDETTI, M.D., INC. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:J
Authorized Official - Last Name:MERCANDETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-291-9285
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-291-9285
Mailing Address - Fax:619-291-9289
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-291-9285
Practice Address - Fax:619-291-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084400Medicaid
CAGR0084400Medicaid