Basic Information
| Provider Information | |||||||||
| NPI: | 1750374104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERCADO | ||||||||
| FirstName: | MELCHOR | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 576649 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953576649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
| FaxNumber: | 2094917184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 CLAUS RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197837880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 35071066 | OH | N | Behavioral Health & Social Service Providers | Psychologist | 2084P0800X | C53189 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000142657 | 01 | OH | ANTHEM | OTHER | 260044712 | 01 | RAILROAD | OTHER | 2018391 | 05 | OH | MEDICAID |