Healthcare Provider Details

I. General information

NPI: 1699146175
Provider Name (Legal Business Name): MARCUS MACHADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 LANG ST
SAN JUAN BAUTISTA CA
95045-9401
US

IV. Provider business mailing address

166 LANG ST
SAN JUAN BAUTISTA CA
95045-9401
US

V. Phone/Fax

Practice location:
  • Phone: 408-390-0094
  • Fax:
Mailing address:
  • Phone: 408-390-0094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: