Provider Demographics
NPI:1326354838
Name:ALTIVEROS, ANDREW MARCOS IMPERIAL (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW MARCOS
Middle Name:IMPERIAL
Last Name:ALTIVEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 STOCKTON BLVD STE 106
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7098
Practice Address - Country:US
Practice Address - Phone:916-262-9002
Practice Address - Fax:916-262-9012
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-127235208000000X
CAC174205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics