Healthcare Provider Details

I. General information

NPI: 1417984782
Provider Name (Legal Business Name): JOSEPHINE BAISA MONTANA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N MOUNTAIN AVE STE 103
UPLAND CA
91786-4163
US

IV. Provider business mailing address

820 N MOUNTAIN AVE STE 103
UPLAND CA
91786-4163
US

V. Phone/Fax

Practice location:
  • Phone: 909-236-5575
  • Fax: 909-222-6936
Mailing address:
  • Phone: 909-236-5575
  • Fax: 909-222-6936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC54399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: