Provider Demographics
NPI:1871577619
Name:MONTANO, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MONTANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78148
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0138
Mailing Address - Country:US
Mailing Address - Phone:951-245-6137
Mailing Address - Fax:951-245-5317
Practice Address - Street 1:520 SUPERIOR AVE STE 200
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3642
Practice Address - Country:US
Practice Address - Phone:949-779-2736
Practice Address - Fax:949-449-8282
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH93284Medicare UPIN