Healthcare Provider Details

I. General information

NPI: 1740404078
Provider Name (Legal Business Name): VICENTE MERCADO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SOUTH SUMMIT ST. UNIT F
CRESCENT CITY FL
32112
US

IV. Provider business mailing address

5104 CONROY RD UNIT 221
ORLANDO FL
32811-3765
US

V. Phone/Fax

Practice location:
  • Phone: 386-698-4720
  • Fax: 386-698-4866
Mailing address:
  • Phone: 407-426-8677
  • Fax: 407-426-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT20078
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: