Provider Demographics
NPI:1962709246
Name:MANRIQUE MERCADO, JOSE EDMUNDO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:EDMUNDO
Last Name:MANRIQUE MERCADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDMUNDO
Other - Middle Name:
Other - Last Name:MANRIQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-8940
Mailing Address - Fax:303-425-9259
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1131
Practice Address - Country:US
Practice Address - Phone:303-415-7610
Practice Address - Fax:303-415-7618
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0050935207Q00000X
IL125-058630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90120078Medicaid