Provider Demographics
NPI:1487610531
Name:MAYO, ABELARDO VERCELES (MD)
Entity type:Individual
Prefix:
First Name:ABELARDO
Middle Name:VERCELES
Last Name:MAYO
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:SUITE P
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3000
Practice Address - Country:US
Practice Address - Phone:209-369-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549010Medicaid
CA00A549010Medicaid