Basic Information
Provider Information | |||||||||
NPI: | 1851335723 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MERCADO | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | MS 315010 | ||||||||
Address2: | PO BOX 3947 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981243947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254673655 | ||||||||
FaxNumber: | 4256356388 | ||||||||
Practice Location | |||||||||
Address1: | 1231 - 116TH AVENUE NE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 98004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256885670 | ||||||||
FaxNumber: | 4256885670 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2006 | ||||||||
LastUpdateDate: | 03/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 2004022179 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 0430844 | KS | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | MD60287498 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 2022404 | 05 | WA |   | MEDICAID | 207225004 | 05 | MO |   | MEDICAID | 200357540A | 05 | KS |   | MEDICAID |