Basic Information
| Provider Information | |||||||||
| NPI: | 1619298643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERCADO-MARMAROSH | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1013A S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | EDNA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779574045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617827820 | ||||||||
| FaxNumber: | 3617825627 | ||||||||
| Practice Location | |||||||||
| Address1: | 1013A S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | EDNA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779574045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617827820 | ||||||||
| FaxNumber: | 3617825627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2010 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10036757 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P8390 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 332697703 | 05 | TX | MEDICAID |