1689717613 NPI number — SAN MARCOS MEDICAL GROUP

Table of content: (NPI 1689717613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689717613 NPI number — SAN MARCOS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN MARCOS MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689717613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10444 LIVEOAK AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92337-7219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-770-8293
Provider Business Mailing Address Fax Number:
909-770-8298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10444 LIVEOAK AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92337-7219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-770-8293
Provider Business Practice Location Address Fax Number:
909-770-8298
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REZK
Authorized Official First Name:
AZER
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
909-376-7715

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  A040591 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A045091 . This is a "MEDICAL LISCENCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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