Healthcare Provider Details

I. General information

NPI: 1053535310
Provider Name (Legal Business Name): MARIO SANTOS YCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 N EL CAMINO REAL SUITE A-210
ENCINITAS CA
92024-1328
US

IV. Provider business mailing address

6399 SAN IGNACIO AVE STE 120
SAN JOSE CA
95119-1215
US

V. Phone/Fax

Practice location:
  • Phone: 760-944-4211
  • Fax: 760-944-9769
Mailing address:
  • Phone: 408-369-5620
  • Fax: 408-904-7730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberG42612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: