Basic Information
| Provider Information | |||||||||
| NPI: | 1508052010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | MARK ANTHONY | ||||||||
| MiddleName: | MAYRINA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10069 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093354188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5957 W RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | BANNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922203058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518450313 | ||||||||
| FaxNumber: | 9517691156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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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 | 207Q00000X | A100509 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CQ2267 | 01 | CA | RR MCR | OTHER | 1174760953 | 05 | CA | MEDICAID | 1508052010 | 05 | CA | MEDICAID | ZZZ43252Z | 01 | CA | BS/TRIWEST | OTHER | P00613391 | 01 | CA | RR MCR | OTHER |