Provider Demographics
NPI:1588691455
Name:MERCANDETTI, ALEX J (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:J
Last Name:MERCANDETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-291-9285
Mailing Address - Fax:619-291-9289
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-291-9285
Practice Address - Fax:619-291-9289
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41199207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084400Medicaid
CAA48490Medicare UPIN
CAW14405Medicare ID - Type Unspecified