Healthcare Provider Details

I. General information

NPI: 1750374104
Provider Name (Legal Business Name): MELCHOR MERCADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAUS RD
MODESTO CA
95355
US

IV. Provider business mailing address

P.O. BOX 576649
MODESTO CA
95357-6649
US

V. Phone/Fax

Practice location:
  • Phone: 419-783-7880
  • Fax:
Mailing address:
  • Phone: 209-571-8330
  • Fax: 209-491-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35071066
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC53189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: