Provider Demographics
NPI:1063412724
Name:REYES, MIRIAM MERCADO (MD)
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:MERCADO
Last Name:REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3425 STONY SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-5437
Mailing Address - Country:US
Mailing Address - Phone:502-367-3100
Mailing Address - Fax:502-491-6619
Practice Address - Street 1:3425 STONY SPRING CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-5437
Practice Address - Country:US
Practice Address - Phone:502-367-3100
Practice Address - Fax:502-491-6619
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY36075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64017189Medicaid
H19624Medicare UPIN
KY64017189Medicaid