Basic Information
| Provider Information | |||||||||
| NPI: | 1154420024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAN BARTOLOME | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | FERNANDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5405 GARDEN GROVE BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926831887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145983707 | ||||||||
| FaxNumber: | 7144220260 | ||||||||
| Practice Location | |||||||||
| Address1: | 5405 GARDEN GROVE BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926831887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145983707 | ||||||||
| FaxNumber: | 7144220260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | A89818 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | A89818 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 174400000X | A89818 | CA | N | Other Service Providers | Specialist | 2083A0300X | A89818 | CA | Y |
No ID Information.