Provider Demographics
NPI:1902958812
Name:EL MERCADO ENT & ALLERGY CLINIC, INC.
Entity Type:Organization
Organization Name:EL MERCADO ENT & ALLERGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:SOMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-842-8011
Mailing Address - Street 1:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:LA FERIA
Mailing Address - State:TX
Mailing Address - Zip Code:78559-1308
Mailing Address - Country:US
Mailing Address - Phone:512-842-8011
Mailing Address - Fax:512-842-3018
Practice Address - Street 1:15520 RANCH ROAD 12
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-6204
Practice Address - Country:US
Practice Address - Phone:512-842-8011
Practice Address - Fax:512-842-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4450207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083734601Medicaid
TX083734601Medicaid