Provider Demographics
NPI:1750374104
Name:MERCADO, MELCHOR (MD)
Entity type:Individual
Prefix:
First Name:MELCHOR
Middle Name:
Last Name:MERCADO
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:P.O. BOX 576649
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6649
Mailing Address - Country:US
Mailing Address - Phone:209-571-8330
Mailing Address - Fax:209-491-7184
Practice Address - Street 1:1501 CLAUS RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:419-783-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071066103T00000X
CAC531892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
260044712OtherRAILROAD
OH000000142657OtherANTHEM
OH2018391Medicaid
260044712OtherRAILROAD
OH000000142657OtherANTHEM