Provider Demographics
NPI:1669908562
Name:MERCADO, JEFFRY JACOB (MD)
Entity type:Individual
Prefix:
First Name:JEFFRY
Middle Name:JACOB
Last Name:MERCADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEFFRY
Other - Middle Name:JACOB
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6719 ALVARADO RD STE 308
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5268
Mailing Address - Country:US
Mailing Address - Phone:619-265-7912
Mailing Address - Fax:
Practice Address - Street 1:6719 ALVARADO RD STE 308
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5268
Practice Address - Country:US
Practice Address - Phone:619-265-7912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178578208100000X
MI4351036470208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program