Provider Demographics
NPI:1063795623
Name:MAGTIBAY, CARLO JERICHO S (MD)
Entity type:Individual
Prefix:DR
First Name:CARLO
Middle Name:JERICHO S
Last Name:MAGTIBAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SULLIVAN AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:415-680-4135
Mailing Address - Fax:
Practice Address - Street 1:1900 SULLIVAN AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:415-680-4135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ630ZMedicare PIN