Provider Demographics
NPI:1538160395
Name:MERCER, KENNETH A (MD MPH)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:MERCER
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 INDEPENDENCE AVE
Mailing Address - Street 2:APT 1M
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1275
Mailing Address - Country:US
Mailing Address - Phone:718-853-0953
Mailing Address - Fax:718-853-0953
Practice Address - Street 1:422 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4002
Practice Address - Country:US
Practice Address - Phone:212-684-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210817207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01893012Medicaid
NY01893012Medicaid
NYG81836Medicare UPIN