Provider Demographics
NPI:1508052010
Name:SANTOS, MARK ANTHONY MAYRINA (MD)
Entity Type:Individual
Prefix:
First Name:MARK ANTHONY
Middle Name:MAYRINA
Last Name:SANTOS
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:5957 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3058
Practice Address - Country:US
Practice Address - Phone:951-845-0313
Practice Address - Fax:951-769-1156
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACQ2267OtherRR MCR
CA1174760953Medicaid
CA1508052010Medicaid
CAZZZ43252ZOtherBS/TRIWEST
CAP00613391OtherRR MCR
CAP00613391Medicare PIN
0A1005090Medicare PIN
CAZZZ43252ZOtherBS/TRIWEST
CA1508052010Medicaid