Provider Demographics
NPI:1265721856
Name:SAN MARCOS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SAN MARCOS MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-376-4438
Mailing Address - Street 1:425 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5153
Mailing Address - Country:US
Mailing Address - Phone:909-546-1050
Mailing Address - Fax:909-546-1061
Practice Address - Street 1:425 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5153
Practice Address - Country:US
Practice Address - Phone:909-546-1050
Practice Address - Fax:909-546-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46022207Q00000X
CAA54098207Q00000X
CAA78410207Q00000X
CAA39805207Q00000X
CA20A10219207Q00000X
CA20A9149207V00000X
CAA92717207V00000X
CAA109432207V00000X
CAA105379207V00000X
CAA60285207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare UPIN