Provider Demographics
NPI:1538587605
Name:GREGORY, DANIELLE MERCADO (DPM)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MERCADO
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:5901 69TH ST
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-2946
Mailing Address - Country:US
Mailing Address - Phone:718-639-3339
Mailing Address - Fax:718-639-5184
Practice Address - Street 1:5901 69TH ST
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2946
Practice Address - Country:US
Practice Address - Phone:718-639-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006895-1213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05234359Medicaid