Provider Demographics
NPI:1245223932
Name:HUATUCO, AIBAR HERBERTO (MD)
Entity Type:Individual
Prefix:
First Name:AIBAR
Middle Name:HERBERTO
Last Name:HUATUCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 BESSIE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3080
Mailing Address - Country:US
Mailing Address - Phone:209-836-1627
Mailing Address - Fax:209-836-5478
Practice Address - Street 1:1530 BESSIE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-836-1627
Practice Address - Fax:209-836-5478
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32630207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A326300Medicaid
CAZZZ29934ZMedicare ID - Type UnspecifiedCORP/GROUP MEDICARE PROV.
CA00A326301Medicare ID - Type UnspecifiedINDIV. PROV ID - MCARE
CA00A326300Medicaid