Healthcare Provider Details

I. General information

NPI: 1326354838
Provider Name (Legal Business Name): ANDREW MARCOS IMPERIAL ALTIVEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STOCKTON BLVD STE 106
SACRAMENTO CA
95816-7098
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-262-9002
  • Fax: 916-262-9012
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-127235
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC174205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: