Provider Demographics
NPI:1679207500
Name:MERCADO, GREGORIO JR (PTA)
Entity type:Individual
Prefix:MR
First Name:GREGORIO
Middle Name:
Last Name:MERCADO
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18622 W COLTER ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-7503
Mailing Address - Country:US
Mailing Address - Phone:845-594-4997
Mailing Address - Fax:
Practice Address - Street 1:18622 W COLTER ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-7503
Practice Address - Country:US
Practice Address - Phone:845-594-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013319208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty