Provider Demographics
NPI:1912128802
Name:SAN BARTOLOME, ANTOINETTE CARMEN (MD)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:CARMEN
Last Name:SAN BARTOLOME
Suffix:
Gender:F
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:P.O. BOX 1410
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-1410
Mailing Address - Country:US
Mailing Address - Phone:805-489-2205
Mailing Address - Fax:805-489-2206
Practice Address - Street 1:901 OAK PARK BOULEVARD
Practice Address - Street 2:SUITE 101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3409
Practice Address - Country:US
Practice Address - Phone:805-489-2205
Practice Address - Fax:805-489-2206
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA87054OtherMEDICAL LICENSE
CABS8970801OtherDEA LICENSE
CABS8970801OtherDEA LICENSE