Provider Demographics
NPI:1255360368
Name:MERCADO, AGUEDA L (MD)
Entity type:Individual
Prefix:
First Name:AGUEDA
Middle Name:L
Last Name:MERCADO
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 1:129 WADSWORTH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033
Mailing Address - Country:US
Mailing Address - Phone:212-781-5891
Mailing Address - Fax:212-740-5163
Practice Address - Street 1:129 WADSWORTH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033
Practice Address - Country:US
Practice Address - Phone:212-781-5891
Practice Address - Fax:212-740-5163
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02604277Medicaid
NYBM7442015OtherDEA
I20753Medicare UPIN
NY308AG1Medicare ID - Type Unspecified