Provider Demographics
NPI:1275655615
Name:SANTOS, MARC DURAN
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:DURAN
Last Name:SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:DURAN
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1212 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1552
Mailing Address - Country:US
Mailing Address - Phone:209-468-8488
Mailing Address - Fax:209-468-8485
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:209-468-8488
Practice Address - Fax:209-468-8485
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29040167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician