MEDICARE: ETERNAMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170100000X	Ph.D. Medical Genetics	ME73229	FL

General Provider Information

NPI Number	:	1508016205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETERNAMD

Provider Business Mailing Address
First Line	:	1307 S INTERNATIONAL PKWY
Second Line	:	SUITE #2091
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1413
Country	:	US
Telephone Number	:	407-771-0404
Fax Number	:	407-771-0405

Provider Business Practice Location Address
First Line	:	1307 S INTERNATIONAL PKWY
Second Line	:	SUITE #2091
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1413
Country	:	US
Telephone Number	:	407-771-0404
Fax Number	:	407-771-0405

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. CARLOS E MERCADO
Credential	:	M.D.
Telephone Number	:	407-771-0404

Provider Enumeration Date	:	09/30/2008
Last Update Date	:	09/30/2008

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Directions to “ETERNAMD ” Practice Location

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