Provider Demographics
NPI:1053036509
Name:MERCADO PENA, IVAN ALEJANDRO
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:ALEJANDRO
Last Name:MERCADO PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 CAMINO DEL RIO N STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1746
Mailing Address - Country:US
Mailing Address - Phone:619-282-8211
Mailing Address - Fax:619-282-1300
Practice Address - Street 1:3530 CAMINO DEL RIO N STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1746
Practice Address - Country:US
Practice Address - Phone:619-282-8211
Practice Address - Fax:619-282-1300
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health