=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821271412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO CARCAMO MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4440 BROCKTON AVE STE 420
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-684-8020
-----------------------------------------------------
Fax | 951-684-8090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4440 BROCKTON AVE STE 420
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-684-8020
-----------------------------------------------------
Fax | 951-684-8090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIO P CARCAMO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 951-684-8020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A35551
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------