Healthcare Provider Details

I. General information

NPI: 1396420394
Provider Name (Legal Business Name): CLINICA SAN MARCOS MEDICAL CENTER APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 LIBERTY BLVD
SOUTH GATE CA
90280-2315
US

IV. Provider business mailing address

3221 LIBERTY BLVD
SOUTH GATE CA
90280-2315
US

V. Phone/Fax

Practice location:
  • Phone: 323-566-9171
  • Fax: 323-566-9178
Mailing address:
  • Phone: 323-566-9171
  • Fax: 323-566-9178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NEIL DAVID KATCHMAN
Title or Position: CEO
Credential: DO
Phone: 323-566-9171