Healthcare Provider Details

I. General information

NPI: 1518916725
Provider Name (Legal Business Name): MARIO P CARCAMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE SUITE 420
RIVERSIDE CA
92501-4068
US

IV. Provider business mailing address

4440 BROCKTON AVE STE 430
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 TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA35551
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA35551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: