Provider Demographics
NPI:1750401055
Name:LAURENCIN, MERCEDES GRACE (MD MPH)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:GRACE
Last Name:LAURENCIN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2203
Mailing Address - Country:US
Mailing Address - Phone:831-421-9535
Mailing Address - Fax:831-421-9290
Practice Address - Street 1:634 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2203
Practice Address - Country:US
Practice Address - Phone:831-421-9535
Practice Address - Fax:831-421-9290
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G510381OtherMEDICARE IDENTIFICATION NUMBER
00G510381OtherMEDICARE IDENTIFICATION NUMBER
CAZZZ01579ZMedicare ID - Type Unspecified