Provider Demographics
NPI:1851319057
Name:MERCADO-DEANE, MARIA-GISELA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA-GISELA
Middle Name:
Last Name:MERCADO-DEANE
Suffix:
Gender:F
Credentials:MD
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 12507
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-0507
Mailing Address - Country:US
Mailing Address - Phone:210-704-2467
Mailing Address - Fax:903-617-5247
Practice Address - Street 1:333 N SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-2467
Practice Address - Fax:903-617-5247
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0860622085P0229X
TXK91292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000203281OtherUNISON
OH1851319057OtherMI MEDICAID
OH363834OtherWELLCARE
OH4305312OtherAETNA
OH000000503628OtherANTHEM
OH733544OtherBUCKEYE
OH2573693Medicaid
WV3810011339OtherWV MEDICAID
OH0304914OtherBCMH
TX378802ZKZCMedicare PIN
OH733544OtherBUCKEYE
OH363834OtherWELLCARE
OH4305312OtherAETNA
OH000000503628OtherANTHEM
OHME4165765Medicare PIN