Provider Demographics
NPI:1154420024
Name:SAN BARTOLOME, MARIO FERNANDO JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:FERNANDO
Last Name:SAN BARTOLOME
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5405 GARDEN GROVE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-1887
Mailing Address - Country:US
Mailing Address - Phone:714-598-3707
Mailing Address - Fax:714-422-0260
Practice Address - Street 1:5405 GARDEN GROVE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-1887
Practice Address - Country:US
Practice Address - Phone:714-598-3707
Practice Address - Fax:714-422-0260
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89818207QA0000X, 207QA0505X, 174400000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG334ZMedicare PIN
CABG334ZMedicare PIN
CABS9096238OtherDEA