Provider Demographics
NPI:1831315134
Name:INOCENCIO, ROBERT DESAMITO
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DESAMITO
Last Name:INOCENCIO
Suffix:
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 1:1821 PARKVIEW GREEN CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-3235
Mailing Address - Country:US
Mailing Address - Phone:408-705-5403
Mailing Address - Fax:
Practice Address - Street 1:1821 PARKVIEW GREEN CIR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-3235
Practice Address - Country:US
Practice Address - Phone:408-705-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health