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General NPI Number Information
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NPI Number | 1154420024
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Entity Type | Individual
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Provider Name | MARIO FERNANDO SAN BARTOLOME JR. MD
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Gender | Male
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 08/08/2019
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Provider Practice Location Address
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Address Line | 5405 GARDEN GROVE BLVD STE 102
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City | WESTMINSTER
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State | CA
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Zip | 92683-1887
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Country | US
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Telephone | 714-598-3707
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Fax | 714-422-0260
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Provider Business Mailing Address
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Address Line | 5405 GARDEN GROVE BLVD STE 102
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City | WESTMINSTER
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State | CA
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Zip | 92683-1887
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Country | US
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Telephone | 714-598-3707
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Fax | 714-422-0260
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0000X
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Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
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License Number | A89818
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | A89818
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A89818
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number | A89818
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License Number State | CA
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