Provider Demographics
NPI:1699146175
Name:MACHADO, MARCUS
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:MACHADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 LANG ST
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-9401
Mailing Address - Country:US
Mailing Address - Phone:408-390-0094
Mailing Address - Fax:
Practice Address - Street 1:166 LANG ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN BAUTISTA
Practice Address - State:CA
Practice Address - Zip Code:95045-9401
Practice Address - Country:US
Practice Address - Phone:408-390-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver