Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | G42612 | CA |
NPI | 1053535310 |
---|---|
Provider Name | Dr. Mario Santos Yco |
First Address | San Jose, CA 95119-1215 |
Second Address | Encinitas, CA 92024-1328 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 01/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G426121 | (05) | CA |
C68050 | (02) | CA |