Provider Demographics
NPI:1679773840
Name:CLINICA MEDICA SAN MARCOS INC
Entity type:Organization
Organization Name:CLINICA MEDICA SAN MARCOS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:323-566-9171
Mailing Address - Street 1:3221 LIBERTY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2315
Mailing Address - Country:US
Mailing Address - Phone:323-566-9171
Mailing Address - Fax:323-566-9178
Practice Address - Street 1:3221 LIBERTY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2315
Practice Address - Country:US
Practice Address - Phone:323-566-9171
Practice Address - Fax:323-566-9178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty