Provider Demographics
NPI:1306955281
Name:MERCADO, JENNIFER (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MERCADO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2174 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2972
Mailing Address - Country:US
Mailing Address - Phone:859-341-2566
Mailing Address - Fax:
Practice Address - Street 1:2174 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2902
Practice Address - Country:US
Practice Address - Phone:859-341-2566
Practice Address - Fax:859-341-2568
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1653DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001659Medicaid
KY61-1169814OtherTAX IDENTIFICATION
KY7100172260Medicaid
000000372897OtherANTHEM
KY61-1169814OtherTAX IDENTIFICATION
KY0740707Medicare ID - Type UnspecifiedJENNIFER MERCADO
KY77001659Medicaid
KY1871641332Medicare NSC
KY9334409Medicare PIN
KY1801949227Medicare NSC