Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | A35551 | CA |
N | 2080P0205X | Pediatric Endocrinologist | A35551 | CA |
NPI | 1518916725 |
---|---|
Provider Name | Mario P Carcamo |
First Address | Riverside, CA 92501-4026 |
Second Address | Riverside, CA 92501-4068 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2006 |
Last Update Date | 12/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A355510 | (05) | CA |
A88565 | (02) |