Provider Demographics
NPI:1497034854
Name:PANTOJA, MARCO JR
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:
Last Name:PANTOJA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 E ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-3104
Mailing Address - Country:US
Mailing Address - Phone:559-608-2118
Mailing Address - Fax:
Practice Address - Street 1:900 QUEBEC AVE
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-9715
Practice Address - Country:US
Practice Address - Phone:559-747-3984
Practice Address - Fax:559-992-7100
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CA101296106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist