Healthcare Provider Details

I. General information

NPI: 1821271412
Provider Name (Legal Business Name): MARIO CARCAMO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE STE 420
RIVERSIDE CA
92501-4026
US

IV. Provider business mailing address

4440 BROCKTON AVE STE 420
RIVERSIDE CA
92501-4026
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-8020
  • Fax: 951-684-8090
Mailing address:
  • Phone: 951-684-8020
  • Fax: 951-684-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA35551
License Number StateCA

VIII. Authorized Official

Name: MARIO P CARCAMO
Title or Position: CEO
Credential: M.D.
Phone: 951-684-8020