Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | C50102 | CA |
Y | 222Z00000X | Podiatrist | C50102 | CA |
NPI | 1013456979 |
---|---|
Provider Name | Mr. Samuel Maldonado JR. |
First Address | Fullerton, CA 92835-3821 |
Second Address | Fullerton, CA 92835-3821 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2017 |
Last Update Date | 13/02/2017 |