Healthcare Provider Details

I. General information

NPI: 1982620811
Provider Name (Legal Business Name): ADA IVETTE MERCADO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 MARIETTA HWY
CANTON GA
30114-2608
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-1955
  • Fax: 770-720-2388
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number51357
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: