Provider Demographics
NPI:1912915463
Name:MERCADO MONTALVO, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:MERCADO MONTALVO
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 1:16STREET J17 CIUDAD UNIVERSITARIA
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-761-6403
Mailing Address - Fax:
Practice Address - Street 1:AVE. CAMPO RICO CALLE 2 BLOQ 1
Practice Address - Street 2:SABANA GARDENS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-276-5272
Practice Address - Fax:787-276-5302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11996207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR90058Medicare ID - Type Unspecified
PRG95007Medicare UPIN