Healthcare Provider Details

I. General information

NPI: 1568527224
Provider Name (Legal Business Name): CARLOS H MONTENEGRO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W 6TH ST STE 3
LOS ANGELES CA
90057-3139
US

IV. Provider business mailing address

PO BOX 94743
PASADENA CA
91109-4743
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9996
  • Fax: 213-483-9831
Mailing address:
  • Phone: 213-483-9996
  • Fax: 213-483-9831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA048811
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: