Provider Demographics
NPI:1114982535
Name:PACADA, MARIO ANTONIO (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ANTONIO
Last Name:PACADA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17999
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-7999
Mailing Address - Country:US
Mailing Address - Phone:562-209-0713
Mailing Address - Fax:562-684-0289
Practice Address - Street 1:501 E HARDY ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4054
Practice Address - Country:US
Practice Address - Phone:562-209-0713
Practice Address - Fax:562-684-0289
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4163213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4767035Medicaid
U71630Medicare UPIN
CAE4163AMedicare ID - Type Unspecified
CA4767035Medicaid