Provider Demographics
NPI:1770604787
Name:CARLOS SANTIVANEZ M.D., INC
Entity type:Organization
Organization Name:CARLOS SANTIVANEZ M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIVANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-582-9061
Mailing Address - Street 1:855 GARNER AVE
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230
Mailing Address - Country:US
Mailing Address - Phone:559-582-9061
Mailing Address - Fax:559-582-9063
Practice Address - Street 1:855 GARNER AVE
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230
Practice Address - Country:US
Practice Address - Phone:559-582-9061
Practice Address - Fax:559-582-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27818ZMedicare ID - Type Unspecified
CAG78211Medicare UPIN