Basic Information
Provider Information | |||||||||
NPI: | 1962709246 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANRIQUE MERCADO | ||||||||
FirstName: | JOSE | ||||||||
MiddleName: | EDMUNDO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANRIQUE | ||||||||
OtherFirstName: | EDMUNDO | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9049 | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803019049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034158940 | ||||||||
FaxNumber: | 3034259259 | ||||||||
Practice Location | |||||||||
Address1: | 3 SUPERIOR DR STE 100B | ||||||||
Address2: |   | ||||||||
City: | SUPERIOR | ||||||||
State: | CO | ||||||||
PostalCode: | 800278653 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034158940 | ||||||||
FaxNumber: | 3034259259 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2011 | ||||||||
LastUpdateDate: | 09/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DR0050935 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 90120078 | 05 | CO |   | MEDICAID |