Healthcare Provider Details

I. General information

NPI: 1366444051
Provider Name (Legal Business Name): CARLOS ALBERTO MERCADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CARLOS ALBERTO MERCADO NEIRA M.D

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 S 1000 E STE 103
ST GEORGE UT
84790-5902
US

IV. Provider business mailing address

624 S 1000 E STE 103
ST GEORGE UT
84790-5902
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-1135
  • Fax: 435-652-1190
Mailing address:
  • Phone: 435-652-1135
  • Fax: 435-652-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number6787613-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1366444051
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: