Healthcare Provider Details

I. General information

NPI: 1376098251
Provider Name (Legal Business Name): CLAUDIA MONTENEGRO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-280-4213
  • Fax: 619-795-9849
Mailing address:
  • Phone: 619-280-4213
  • Fax: 619-795-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A18132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: