Healthcare Provider Details

I. General information

NPI: 1306955281
Provider Name (Legal Business Name): JENNIFER MERCADO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2174 DIXIE HWY
FORT MITCHELL KY
41017-2902
US

IV. Provider business mailing address

2174 DIXIE HWY
FORT MITCHELL KY
41017-2972
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-2566
  • Fax: 859-341-2568
Mailing address:
  • Phone: 859-341-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1653DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: