Basic Information
| Provider Information | |||||||||
| NPI: | 1982620811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERCADO | ||||||||
| FirstName: | ADA | ||||||||
| MiddleName: | IVETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Practice Location | |||||||||
| Address1: | 687 MARIETTA HWY | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301142608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707041955 | ||||||||
| FaxNumber: | 7707202388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/19/2015 | ||||||||
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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 | 207RC0000X | 51357 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000967029K | 05 | GA | MEDICAID | 000967029M | 05 | GA | MEDICAID | 000967029I | 05 | GA | MEDICAID | 000967029L | 05 | GA | MEDICAID | 000967029G | 05 | GA | MEDICAID |