Provider Demographics
NPI:1285711812
Name:LUZVIMINDA T MONTECILLO MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LUZVIMINDA T MONTECILLO MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:
Authorized Official - Last Name:TAGORDA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-673-2764
Mailing Address - Street 1:645 AERICK ST STE 1
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4882
Mailing Address - Country:US
Mailing Address - Phone:310-673-2764
Mailing Address - Fax:310-673-2403
Practice Address - Street 1:645 AERICK STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4882
Practice Address - Country:US
Practice Address - Phone:310-673-2764
Practice Address - Fax:310-673-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A522900Medicaid
CA00A522900Medicaid
CA00A52290OtherBLUE SHIELD
CAW18574Medicare ID - Type Unspecified