Provider Demographics
NPI:1124052691
Name:MERCED, JOSE EDGARDO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:EDGARDO
Last Name:MERCED
Suffix:
Gender:M
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 81023
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-1023
Mailing Address - Country:US
Mailing Address - Phone:337-769-3002
Mailing Address - Fax:
Practice Address - Street 1:433 LA NEUVILLE RD
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5212
Practice Address - Country:US
Practice Address - Phone:337-769-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA21815207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA21815OtherMEDICAL LICENSE
LA1982491Medicaid
LA04-02386OtherUNITED HEALTHCARE
LA1982491Medicaid
LA5CG51Medicare PIN
LA5U138Medicare PIN