Provider Demographics
NPI:1518916725
Name:CARCAMO, MARIO P (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:P
Last Name:CARCAMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4440 BROCKTON AVE STE 430
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4026
Mailing Address - Country:US
Mailing Address - Phone:951-684-8020
Mailing Address - Fax:951-684-8090
Practice Address - Street 1:4440 BROCKTON AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4068
Practice Address - Country:US
Practice Address - Phone:951-684-8020
Practice Address - Fax:951-684-8090
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA355512080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A355510Medicaid
A88565Medicare UPIN