Basic Information
| Provider Information | |||||||||
| NPI: | 1932394673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERCADO | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | GUTIERREZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 SW SEDGWICK RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983676425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 451 SW SEDGWICK RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983676425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 12/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 57.010061 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD00049124 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8513640 | 05 | WA | MEDICAID | 8948914 | 01 | WA | CRIME VICTIMS | OTHER | 0236729 | 01 | WA | L&I | OTHER |