Healthcare Provider Details

I. General information

NPI: 1144451659
Provider Name (Legal Business Name): HIPOLITO G. MARIANO, JR., MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 E OLIVE AVE
FRESNO CA
93702-1030
US

IV. Provider business mailing address

3121 E OLIVE AVE
FRESNO CA
93702-1030
US

V. Phone/Fax

Practice location:
  • Phone: 559-412-4927
  • Fax: 559-493-5028
Mailing address:
  • Phone: 559-412-4927
  • Fax: 559-493-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA88903
License Number StateCA

VIII. Authorized Official

Name: DR. HIPOLITO GALLARDO MARIANO JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-412-4927