Provider Demographics
NPI:1427887769
Name:QUINTOS, MARK C
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:QUINTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:QUINTOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2864 SHELTER HILL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8628
Mailing Address - Country:US
Mailing Address - Phone:415-990-2476
Mailing Address - Fax:
Practice Address - Street 1:2864 SHELTER HILL DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-8628
Practice Address - Country:US
Practice Address - Phone:415-990-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24000350172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver