Provider Demographics
NPI:1952431058
Name:MERCADO, LUMINADO AGONIA (PT)
Entity Type:Individual
Prefix:
First Name:LUMINADO
Middle Name:AGONIA
Last Name:MERCADO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LITTLE BRITAIN RD
Mailing Address - Street 2:STE 202
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550
Mailing Address - Country:US
Mailing Address - Phone:845-567-7789
Mailing Address - Fax:845-567-1411
Practice Address - Street 1:10 LITTLE BRITAIN RD
Practice Address - Street 2:STE 202
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-567-7789
Practice Address - Fax:845-567-1411
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ01V41Medicare ID - Type Unspecified